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Name * |
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| Address |
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| Email * |
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| Mobile * |
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| Present Weight |
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| Height |
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| Gender * | Male Female |
| Do you want to Loose/Gain weight? * | Loose Gain |
| How much weight do you want to Lose/Gain? |
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| What therapy have you tried? |
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| What do you take in Breakfast? |
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| What do you take in Lunch? |
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| What do you take in Dinner? |
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| Snacks in between? |
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| Tea / Coffee / Cold drinks (How much)? |
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| Smoking |
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| Alcohol |
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| Are you on any medication? |
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| How much water do you drink per day? |
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