Personal & Family Health
Information Form (PFHI)
Information Form (PFHI)
1
Why do you need to fill the PFHI form?
- Many health conditions have a genetic component. The PFHI form helps Insightome team assess whether certain conditions run in your family in order to evaluate your pregnancy risks, if any
- Your Personal and family health information (PFHI) is a record of any health treatments or conditions experienced by you or your family that could potentially affect the health of your pregnancy or your baby.
- For example, if your mom had a pregnancy-related condition like gestational diabetes, preeclampsia or prenatal depression, you’re statistically more likely to experience it too.
- Insightome’s Genetic and Nutritional counselors plan personalized lifestyle and diet recommendations by combining your Insightome pregnancy genetic report & your PFHI inputs.
2
What are the various components of PFHI form?
- PFHI covers two categories: Your Health Information and Your Families Health Information.
- PFHI captures the medical and environment (lifestyle and nutrition) information about you and your family to assess the interplay between environmental factors & your genetic profile and its impact on disease manifestation to provide actionable insights to improve health outcomes in pregnancy.
3
How you should fill the PFHI form?
- Please read all the questions carefully and take your time answering them. Concentrate while reading the questions and try to answer them as accurately as possible.
- Use (✓) to mark the response that best represents your situation. Some questions have more than one answer. You may mark all the answers that you find appropriate.
- If you wish to explain or add a medical, lifestyle or nutritional condition for yourself or a family member, separate space has been provided for you to share the details.
4
Should you share your medical reports with the PFHI form?
- Insightome endeavors to improve your health through genomics driven actionable insights. We recommend that you should share your latest medical reports and relevant records as this would help Insightome’s accredited counselors to provide informed interventions to you by evaluating your present health parameters taking into account your genome profile.
- You may email your records at info@insightome.in. You may also speak with Insightome customer care team at +91 8976 757 486 if you need any assistance in filling the form or sharing any documents.
5
How would your privacy concerns be addressed?
- Your privacy is our priority. Your personal & family history will be entered into a confidential computerized database. We take all due measures to ensure that your data is safeguarded & is de-identified for research purposes.
- You may be contacted in the future about research studies and upcoming genetic tests that would offer newer and diverse research based insights
D.
Nutrition Profile
Food Intorlerance
(Tick on appropriate)
Do you experience nausea, bloating, diarrhea, or discomfort on consuming
Gluten
Lactose
Casein
Caffiene
Diet Patterns
(Tick on appropriate)
Dietary Habbit
Explanation
No animal product
Eat dairy products but no eggs
Avoid all animal products except eggs
Eat dairy products & eggs but no animal flesh
Eat animal flesh
Diet Composition
How often do you consume
Meat and Meat Products*
Choose one
Vegetable & Non-animal Products*
Choose one
Eating Outdoors*
How often do you eat outside per week
Hydration Habbits*
Daily water intake (250 ml glass used at home)
Eating Frequency*
Daily meals taken (A fruit/yogurt/glass of milk treated as a single snack)
Emotional Eating*
Do you eat when you are stressed/unhappy/angry
Supplement Consumption*
Do you take Nutritional Supplements
Any other supplement
Your most important meal*
Which meal is your main meal of the day
Food additives (Salt/Sugar/Oil)
Which type of salt do you use for daily cooking*
(Tick on appropriate)
Do you get a craving for salty / spicy foods?*
(Tick on appropriate)
Do you add Table salt to your diet.*
(Tick on appropriate)
How often do you consume the following items?*
(Tick on appropriate)
FOOD ITEM
FREQUENCY
PICKLES / CHUTNEYS*
Choose one
PAPAD*
Choose one
PACKED FRIED FOODS*
Choose one
(CHIPS, SAVORIES, SALTY SNACKS )*
Choose one
SPREADS AND KETCHUP/ SAUCES / CHEESE*
Choose one
PROCESSED FOODS*
Choose one
TINNED FOODS ( VEGGIES/ BEANS /NON-VEG)*
Choose one
BAKERY ITEMS*
Choose one
Do you use natural substitutes for sugar?*
(Tick on appropriate)
Do you use sythetic sugar substitutes?*
(Tick on appropriate)
If yes specify*
Do you get cravings for sweets*
(Tick on appropriate)
If yes, how often*
What do you prefer to eat at this time?
Variety/Types of Oils used
Any other personal nutritional information that you would like to add/explain:
2
Family Health Information
Please fill the number of blood relations to be included in test (You and your parents are already included)
Total number of females :
Sister
Daughter
Total number of males :
Brother
Son
| Relationship | Parents | |
|---|---|---|
| Conditions | ||
| Metabolic | ||
| Diabetes | ||
| Cholesterol | ||
| Thyroid disease | ||
| Obesity | ||
| Cardiac | ||
| Hypertension | ||
| Coronary heart disease | ||
| Stroke | ||
| Epilepsy | ||
| Behavioral | ||
| Depression | ||
| Anxiety | ||
| Psychiatric illness | ||
| Gastrointestinal | ||
| Acidity | ||
| Constipation | ||
| Irritable bowel | ||
| Other systems | ||
| Hepatitis | ||
| Kidney disease | ||
| Rheumatoid arthritis | ||
| Allergy | ||
| Asthma | ||
| Tobacco addiction | ||
| Alcohol addiction | ||