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Menstruating Individual Intake

Full name

Preferred pronouns

WhatsApp contact

Age

Height in ft

Weight in kilo grams

Profession

Where did you hear about Jiah from?

Dietary preference

Who generally cooks your meals for you?

If you use meal subscription plans, please add it in 'Other' with details of the subscription company

How many meals you consume in the day?

Include snacking as a meal

How often do you eat out/order food? Is there a specific reason for you to order out/ get takeaways/eat out?

Your favorite cuisine

Your favorite Dish

Food item/s which you wouldn't consume to save your life

(Items you don't like)

Now rewind and tell me everything that you ate in the last 24 hours. Be as honest as you can.

Please mention in the following format:

09:00am: 1 Cucumber sandwich

11:00am: An apple

1:00pm : Rajma Chawal, 1 bowl Curd etc.

What do you generally consume for breakfast?

If you generally skip breakfast, mention the reason for you to do so

What do you generally consume for lunch?

What do you generally consume for dinner?

How much water do you consume at an average everyday?

A
B
C
D
E
F

What other beverage do you generally consume? At what time and in what quantities?

(Tea, coffee, matcha, green tea, milkshake, other)

Do you consume alcohol? If yes, mention: Frequency and Quantity

Do you smoke/ smoke up? If yes, mention: Frequency and Quantity

How are you feeling right now?

Feel free to tell me elaborately and with complete details

General Health and Medical history

Have you previously gone on any sort of diets? If yes, what kind of diet was it.

Explain elaborately what you ate, what you avoided eating and how many meals did you eat.

Have you heard of Intermittent fasting? What are your thoughts on it?

What are your thoughts on Gluten?

Do have any any food intolerances/ allergies?

Any food item that causes irritation, allergies, skin problems, etc.

Elaborately explain to me your medical history. From roughly, the start of your teenage, till date.

This includes any medical conditions you have been diagnosed with. Including PCOS, Diabetes, Thyroid, etc.

Are you on any kind of medication at present?

Please mention names of the medicines and the reason why you're consuming them.

What are your bowel movements like?

How many times do you poop? Around what time? Texture (Refer to this link to know your texture type)

What is your sleep pattern like?

What time do you sleep? What time you wake up? Do you have broken sleep/disturbed sleep, or do you sleep comfortably? Any history you'd like me to be aware of?

How many days do you generally bleed for on your period?

How many days of bleeding is normal for you?

(since menarche)

The last date you got your period

How long is your cycle generally?

(How many days of gap do you have between two period cycles)

What was your mood typically, before your period?

Tap on all that apply to you
A
B
C
D
E
F
G
H
I
J
K
L
M

Have you ever experienced painful periods?

A
B
C
D
E

What are your health and body goals?