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Waist Circumference

Daily Water Intake

Daily Energy Requirements

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Personal Information

First name		Last name
Date of birth		Sex
Relation status		Number of kids
Nationality		Address
Phone		Mobile
Fax		Email
Work		Work address
Education		Favorit sport
Religion
How did you hear about DDC?

Medical Information

Digestion Problems		Do you diabetes?
Medical Story
Blood Cholesterol		Thyroid Gland Problems
Joints Pain		Hypertension
Previous Diets
Surgical Story
Weight (kg)		Height (cm)
Waist circumferance		Hip circumferance (cm)
Smoker		If yes how much
Drinker		If yes how much
Weight Medication		Daily medication
Your recent Laboratory tests and if there is anything abnormal inform me?
Breastfeeding		Drug and food allergy
Number of daily glasses of water		Number of daily coffee and tea cups
How many meals do you eat every day?		Are you pregnant
Food items you hate