Questionair

Volunteers Details
First Name
Last Name
Age
Sex	Male Female
Address
Married/Unmarried	Married Unmarried
Telephone
Cell No
E-mail
Religion
Origin of State in India
Cell No
No of Brother/ Sister	0 1 2 3 4 5 6 7 8 9 10
No of Son/Daughter	0 1 2 3 4 5 6 7 8 9 10
Time spent on travel Hr./ day
Living in	Village City
Diseases	Diabetes Blood Pressure Obesity Arthritis Heart Disease Other
Family Details
Family Type	Nuclear Joint
No of Family Members	0 1 2 3 4 5 6 7 8 9 10 >10
No of Male Members	0 1 2 3 4 5 6 7 8 9 10 >10
No of Male Members	0 1 2 3 4 5 6 7 8 9 10 >10
Per capita Income	More than 500/- per month More than 2000/- per month More than 5000/- per month
Monthly consumption (in Kg) :
Veg oil
Milk & its products
Non veg
Ghee
Wheat
Rice
Pulses
Fruits
vegetables
Education
Primary education
High school
Graduation
Post Graduation
Professional
Periodical bath in rivers(per 3 month in a year)
Frequency to visit worship places	Daily Weekly Monthly Some time
Spiritual fast	Weekly Monthly
Addiction
smoke	/day
Tobacco/ Gutuka	/day
Alcohal	ml/month
Others
Drinking Alcohal (prefered mostly)	Alone in room Society
Constitutional Detail
Body weight
Height
Circumference of belly
Chest
Hip
Respiration/min
Pulse/ min
Stamina- Capacity to climb number of steps on stair case
number of sit up
without raised respiration; duration of exercise- Yoga/Heavy- Hr. /day
Skin
Oily Dry
hair on Skin
Less More Soft Deep Rooted
Sleeping Habit
Hours of sleep	H rs.
Time to go at bed for sleeping	PM
First sleep break in night	2 AM 4 AM 6 AM
Bladder Habits
No. of urination per day
Bowel Habits
No. of stool passing per day
Drinking Habits
Water per day	Litres
Digestive Power
Digestive Power	Bad Poor
Wound Healing Rate
Wound Healing Rate	Quick Delayed
Personality
Personality	Introvert Extrovert.
Longevity details of family
Personality	50-60 60-80. more than 80.
Eating Habits
Number of meals /day	heavy. light. No. of hunger signals in whole day. Infection frequency / year.
Diet Preference
Diet Preference	Rice Roti Vegetable Pulse Milk Products Ghee Puri-Paratha Deep Fried food
Taste Preference
Taste Preference	Sweets Salty Acidic Bitter Cold drinks processed Juice shake