Health Declaration Form — Nutri Physician

Let's begin

Tell us a little
about you.

The basics. All your information is confidential and reviewed only by Dt. Krishi Somanna and the NABH-trained Nutri Physician team.

First Name *

Please enter your first name.

Gender *

Female Male Other

Date of Birth *

City *

WhatsApp Number *

+91

We'll send your plan and updates here.

Email *

How did you hear about us? *

Body metrics

Your numbers.

Rough estimates are fine — we'll refine these on your first call. If you don't know hips/waist exactly, use a tape or skip and we'll measure on call.

Height *

ft

in

e.g. 5 ft 11 in

Weight *

kg

Hips

in

Widest part of your hips

Waist

in

Narrowest part, just above belly button

Daily life

How you live
day to day.

No judgement — honest answers help us build a plan that fits your actual routine, not an idealised version of it.

Food Habit *

Vegetarian Non-Vegetarian Eggetarian Vegan

Beverage Habits *

Select all that apply — daily tea/coffee/alcohol consumption

How active are you in a day? *

SedentaryMostly sitting — desk job, minimal movement Lightly ActiveLight walking, light chores, standing job Moderately ActiveRegular exercise 3–4× a week, on your feet Very ActiveDaily intense workout or physical job

Average sleep (per 24 hours) *

hours

Total — including naps

Daily time for physical activity *

min

How much you can realistically commit

Diet preferences

Food rules that matter
to you.

Allergies, dislikes, religious restrictions — everything we need to avoid putting on your plate.

Foods you dislike or avoid religiously

Cultural, religious, or just personal — we'll respect all of it.

Any food allergies? *

Critical — please don't skip even if mild.

Your concerns

What's bothering you
right now?

Symptoms, discomfort, conditions, lab reports, medications — anything you want Krishi to know before your first call. The more honest, the better the plan.

Describe your concerns, symptoms, or anything you're uncomfortable with *

Take your time. Mention current medications, past diagnoses, recent lab results, family history, energy levels, mood — anything relevant.

Almost there

Photos & final consent.

We use full-body photos as a baseline — to measure visible progress alongside your lab reports. Wear fitted clothing; clear lighting helps.

Upload clear photos showing your full body *

📸

Drop photos here or click to upload

Front, side & back views recommended · JPG / PNG · Max 10MB each

🔒 Photos are stored privately and only Krishi has access. Never shared without your explicit permission.

By submitting this form, I confirm that:

All information I've provided is accurate to the best of my knowledge.
I understand Nutri Physician provides dietary guidance and is not a substitute for medical treatment from a qualified doctor.
I will inform my doctor before making any change to prescribed medication.
My data — including photos, lab reports and personal details — will be kept strictly confidential and used only to design my plan.
I consent to receiving my plan, follow-up messages and check-ins via WhatsApp and email.

I have read and agree to the terms above and to Nutri Physician's Privacy Policy and Terms & Conditions.

✓

Thank you, friend.
We've received your declaration.

Krishi will personally review every answer you've shared. Complete your enrolment payment below to lock in your 12-week programme — you'll then hear from us on WhatsApp within 24 hours to schedule your first call.

What happens next

Krishi reviews your declaration personally — usually within a few hours of receiving it.
You'll get a WhatsApp message confirming your plan recommendation (Wellness or Therapeutic).
We schedule your first detailed consultation call — usually 45 minutes — to refine measurements and goals.
Your 12-week plan begins. Weekly check-ins. Monthly labs. Lifetime free re-consultations.

Message Krishi on WhatsApp →

Tell us a littleabout you.

Your numbers.

How you liveday to day.

Food rules that matterto you.

What's bothering youright now?