HISTORY - BALANTIA APP

Contact details

What is your full name?

First name

Last name

What is your email address?

Confirm What is your email address?

What is your occupation?

Which city do you live in?

State

Which city do you live in?

What is your phone number?

How did you hear about balantia?

Specify

Are you currently using the balantia app?

👍 Yes

👎 No

Profile

Preferred units

Metric (kg, cm)

Imperial (lb, ft)

What is your height?

ft in

What is your current weight?

lbs

What is your height?

cm

What is your current weight?

kg

What is your sex?

♂️ Male

♀️ Female

What is your date of birth?

Do you know your body fat percentage?

Goals

What are your nutrition goals?

Specify

Is breastfeeding exclusive?

👍 Yes

👎No

Which week of pregnancy are you currently in?

What is your weight goal?

↘️ Weight loss

➡️ Weight maintenance

↗️ Weight gain

What is your desired weight?

How quickly would you like your weight to change?

Slow (~0.3 kg/week)

Moderate (~0.5 kg/week)

Standard (~0.75 kg/week)

Fast (~1 kg/week)

Very fast (~1.3 kg/week)

Not sure

Πόσο γρήγορα θα θέλατε να αλλάξει το βάρος σας;

Slow (~0.3 kg/week)

Moderate (~0.5 kg/week)

Standard (~0.75 kg/week)

Fast (~1 kg/week)

Very fast (~1.3 kg/week)

Not sure

How quickly would you like your weight to change?

Slow (~0.7 lbs/week)

Moderate (~1.1 lbs/week)

Standard (~1.7 lbs/week)

Fast (~2.2 lbs/week)

Very fast (~2.9 lbs/week)

Not sure

How quickly would you like your weight to change?

Slow (~0.7 lbs/week)

Moderate (~1.1 lbs/week)

Standard (~1.7 lbs/week)

Fast (~2.2 lbs/week)

Very fast (~2.9 lbs/week)

Not sure

Have you followed a diet before?

👍 No

👎 Yes

How many kg did you lose?

How many lbs did you lose?

Did you regain weight afterwards?

👎 No

👍 Ναι

Health information

Do you have any diagnosed medical conditions?

👎 No

👍 Yes

Specify

Have you had any surgeries?

👎 No

👍 Yes

Specify

Do you have any allergies?

👎 No

👍 Yes

Specify

Do you have any food intolerances?

👎 No

👍 Yes

Specify

Do you have recent medical test results?

👎 No

👍 Yes

File upload

Maximum file size: 134.22MB

Are you currently taking any medications?

👎 No

👍 Yes

Medication

Medication name

Reason

Dosage

Frequency of use

Add Medication Remove Medication

Are you using GLP-1 therapy (eg Ozempic, Wegovy, Mounjaro)?

👎 No

👍 Yes

GLP-1

Medication name

Dosage

Duration of use

Your results so far?

Add Medication Remove Medication

Have you previously used medication for weight loss?

👎 No

👍 Yes

Medication

Medication name

Dosage

How long ago?

Your results?

Add Medication Remove Medication

Do you take dietary supplements? (eg protein powder, creatine, omega-3, vitamin D)

👎 No

👍 Yes

Dietary supplements

Supplement Name

Reason

Dosage

Frequency of use

Add Medication Remove Medication

Dietary habits

Do you follow a specific dietary pattern?

Specify

Do you follow intermittent fasting?

👎 No

👍 Yes

Start time

End time

Do you have any dislikes?

👎 No

👍 Yes

List foods you do not consume

Are there foods you especially like?

👎 No

👍 Yes

List foods you especially like

Do you prefer seasonal foods?

👎 No

👍 Yes

Describe your typical breakfast

Do you usually eat breakfast?

👎 No

👍 Yes

Breakfast preferences

Homemade (eg eggs, toast, oatmeal, yogurt with fruit)

On the go (eg bakery items, coffee shop options)

Ready made meal (eg meal delivery services, labeled meals)

Other

Describe your typical breakfast

Είναι το πρωινό σας παρόμοιο τα Σαββατοκύριακα;

👎 No, it is different

👍 Yes, it is similar

Please describe:

Describe your typical lunch

Do you usually eat lunch?

👎 No

👍 Yes

Lunch preferences

Homemade (eg grilled chicken with rice, pasta, cooked meals)

Restaurant (eg business lunch, burger & fries, pasta dish, sushi combo)

Quick meal (eg boiled eggs, sandwich, wrap, toast, instant noodles, tuna salad)

Έτοιμο γεύμα (π.χ. υπηρεσίες παράδοσης γευμάτων, γεύματα με ετικέτες)

Other

Describe your typical lunch

Is your lunch the same on weekends?

👎 No, it is different

👍 Yes, it is similar

Please describe:

Describe your typical dinner

Do you usually eat dinner?

👎 No

👍 Yes

Dinner preferences

Homemade (eg steak with vegetables, baked fish, cooked meals)

Restaurant (eg steakhouse meal, sushi dinner, pasta dish, takeaway)

Quick meal (eg boiled eggs, omelette, toast, instant noodles, tuna salad)

Ready made meal (eg meal delivery services, labeled meals)

Other

Describe your typical dinner

Is your dinner the same on weekends?

👎 No, it is different

👍 Yes, it is similar

Please describe:

Describe the snacks you usually eat.

Do you usually eat snacks between meals?

👎 No

👍 Yes

How many snacks do you usually have per day?

Describe the snacks you usually eat.

Are your snacks the same on weekends?

👎 No, it is different

👍 Yes, it is similar

Please describe:

Do you add salt to your food?

👎 No

👍 Yes

No preference

What portion size do you usually eat?

Small portions

Standard portions

Large portions

How often do you eat sweets?

What types of sweets do you usually choose?

How many sweets do you usually consume?

Few

Some

Many

Water

How much water do you drink per day?

Caffeine

Do you drink coffee during the day?

What type of coffee do you usually drink?

Please specify

Does your coffee contain caffeine?

With caffeine

Without caffeine (decaf)

Both

Do you add sugar / sweeteners to your coffee?

👎 No

👍 Yes

Τύπος γλυκαντικού:

Sugar

Saccharin

Stevia

OtherOtherOtherOther

Quantity:

Do you add milk to your coffee?

👎 No

👍 Yes

Type of milk:

Amount of milk:

What type of milk does it usually contain?

Whole milk

Semi-skimmed milk

Skimmed milk

Evaporated milk

Γάλα φυτικής προέλευσης (π.χ. αμυγδάλου, σόγιας, βρώμης)

I don’t know

OtherOther

Beverages

Do you drink any other beverages?

👎 No

👍 Yed

Please specify

Alcohol

Do you consume alcohol?

How much do you usually consume?

1 drink

2–3 drinks

4–6 drinks

More than 6 drinks

Type of alcohol you usually prefer (ex. wine, beer, vodka)

Physical activity & lifestyle

Ηοw often do you exercise?

Sedentary lifestyle (no structured exercise)

Lightly active(1–2 workouts per week)

Moderately active (3–4 workouts per week)

Very active (5+ workouts per week)

How active are you during the day?

Mostly sitting (desk work, minimal movement)

Light movement (some walking or standing during the day)

Active job (standing or walking most of the day)

Physically demanding (manual labor, construction, heavy lifting)

Do You Smoke?

👎 No

👍 Yes

How many years have you been smoking?

Number of cigarettes per day:

How many hours do you usually sleep per night?

Less than 6 hours

6–8 hours

More than 8 hours

I don’t know

How would you rate your sleep quality?

Good

Fair

Poor

Submit questionnaire

Is there anything else you would like your dietitian to know?

Consent & Declaration

I confirm that the information I have provided is true, complete and accurate.

I confirm that I have read and agree to the Privacy Policy and Terms of Use.

I consent to the collection, review, and processing of the health and personal information I provide for the purpose of nutritional evaluation, service delivery, and ongoing support, in accordance with the Privacy Policy and applicable data protection laws.

Balantia Health & Nutrition History Form

Contact details

Profile

Goals

Health information

Medication

GLP-1

Medication

Dietary supplements

Dietary habits

Describe your typical breakfast

Describe your typical lunch

Describe your typical dinner

Describe the snacks you usually eat.

How often do you eat sweets?

Water

Caffeine

Beverages

Alcohol

Physical activity & lifestyle

Submit questionnaire