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30B, R B Plaza, 1st Floor, Tankal Road, Rankuwa, Chikhli, Gujarat

+91 81408 88199

inquire.getfitwithvivek@gmail.com

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Personal Details

Name

Phone

Email

Age

Gender

Profession

Country

Food Preference

Present Weight (kg)

Target Weight (kg)

Height (ft)

Symtoms, Medical Conditions & Routine

Any medical history you want to discuss * Required

Blood Pressure

Diabetic

PCOD

Thyroid

Joint Problem

Gallbladder Removed

Gallstone

Kidney Stone

Any other

None

Write chief health day-to-day symptoms of your health in order of your importance like acidity, fatigue, dry eyes, and any food allergies?

Your Breakfast Time

Your Snacks Time

Choose a time

Your Lunch Time

Choose a time

Your Dinner Time

Choose a time

Are you taking any Supplements, Herbs at the moment? What's the dosage?

How many hours do you sleep at night?

Your Sleep Time

Choose a time

Your Wakeup Time

Choose a time

Exercise & Test Reports

How often do you exercise?

How many hours do you spend in a gym at a time?

Are you open to join a Gym?

Yes

No

Maybe

How many blood test reports do yo have from below list?

Fasting Blood Glucose

Vitamin D

Uric Acid

Lipid Profile

Liver Function

None

I being aware of my medical conditions wants to follow the diet recommended by Mr. Vivek Barot. During this diet period if anything unusual happens, I will be responsible for that, not a concerned person.

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