Demographics

Full Name

Age

Gender

Email

Phone Number

Anthropometrics

Height (cm)

Weight (kg)

Are you currently pregnant or breastfeeding?

Yes No

Have you been diagnosed with obesity (BMI ≥ 30)?

Yes No

Do you have any of the following conditions? (Check all that apply)

Diabetes
Hypertension
Cardiac Disease
Hyperlipidemia
None

Are you currently taking medications for weight loss?

Yes No

Do you participate in regular physical activity?

Yes No

If yes, how many days per week?

Are you currently enrolled in any weight loss programs?

Yes No

Have you had any bariatric surgery?

Yes No

Do you have any severe psychiatric disorders?

Yes No

Do you have any other major illnesses?

Yes No