Health Questionnaire Health QuestionnairePlease enable JavaScript in your browser to complete this form. - Step 1 of 2Name *FirstLastGenderMaleFemaleEmail *Age *Job *Current Weight *20 Years Weight *Desired Weight *Height *Waist Circumference *Abdominal Circumference (2cm below the navel) *Hip Circumference *Chest Circumference *Upper Leg *Lower Leg (just over the knee) *Wrist Circumference *Early morning Body temperature (to be measured in the range 07:00 a.m. to 08:00 a.m.) *Physical activity: *Physical activity weekly frequency: *NextWhat did you have for Breakfast? Day-1 *Last 3 days food diaryWhat did you have for Lunch? Day-1 *Last 3 days food diaryWhat did you have for Dinner? Day-1 *Last 3 days food diaryHow much water did you drink (still or sparkling water)? Day-1 *Last 3 days food diaryDid you have snacks throughout the day (write when and what)? Day-1 *Last 3 days food diaryWhat did you have for Breakfast? Day-2 *Last 3 days food diaryWhat did you have for Lunch? Day-2 *Last 3 days food diaryWhat did you have for Dinner? Day-2 *Last 3 days food diaryHow much water did you drink (still or sparkling water)? Day-2 *Last 3 days food diaryDid you have snacks throughout the day (write when and what)? Day-2 *Last 3 days food diaryWhat did you have for Breakfast? Day-3 *Last 3 days food diaryWhat did you have for Lunch? Day-3 *Last 3 days food diaryWhat did you have for Dinner? Day-3 *Last 3 days food diaryHow much water did you drink (still or sparkling water)? Day-3 *Last 3 days food diaryDid you have snacks throughout the day (write when and what)? Day-3 *Last 3 days food diaryDo you use to have sugary drinks? *YesNoDo you use to have alcoholic drinks? *YesNoDo you have any digestive system functional disorders or skin reactions that can be associated to some eaten foods? If yes, write a short description: *Do you have dental amalgams? *YesNoWhen did you make your last blood test? Any out of range values in your blood test results? * Any Medicines ? If yes, write the name of the medicines and why do you take?Do you have a good relationship with your body? *Are you anxious? *YesNoAre you or depressed? *YesNoAre you stressed out? *YesNo Are you incline to over think *About Your Past LifePrefer Focus On Your FutureAre you frequently hungry? *YesNoDoes it ever happen to you to eat without control? *YesNoHow many hours do you sleep? *Do you struggle to fall asleep? *YesNoDoes it ever happen you to wake up while sleeping during the night? *YesNoDo you have a slow digestion? *YesNoDo you suffer for gastritis? *YesNoDo you have gastroesophageal reflux disease? *YesNoDo you suffer for skin rushes? *YesNoWhen you wake up do you feel nausea with a lack of appetite? *YesNoWhen you wake up do you feel a bitter taste in your mouth? *YesNoDo you suffer for constipation? *YesNoDo you suffer for diarrhoea? *YesNoHow many times in a day do you empty your bowel? Selected Value: 0 Do you suffer for colitis (irritable bowel syndrome)? *YesNoDo you suffer for meteorism? *YesNo Do you have a frequently swollen belly? *YesNoDoes sometimes your belly hurt on its left side? *YesNoDoes sometimes your belly hurts on its right side? *YesNoDo you have swollen feet or swollen hands when you wake up or in the evening? *YesNoDo you have a regular menstrual cycle? *YesNoDo you feel very swollen before or during your menstruations days? *YesNoHow many days before do you start feeling swollen? *Do you have plentiful menstrual blood losses? *YesNoAre you in menopause? *YesNoHow long time have you been in menopause? *Do you suffer for muscular cramps? *YesNoDo you suffer for muscles pain? *YesNoDo you feel tired when you wake up in the morning? *YesNoDo you get tired easily? *YesNoAre you Hypertensive? *YesNoAre you Hypotensive? *YesNoDo you have high triglycerides? *YesNoDo you have high cholesterol? *YesNoDo you have a high blood glucose? *YesNoDo you have low iron? *YesNoDo you have low red cells count? *YesNoDo you have cellulite? *YesNoDo you have dry skin? *YesNoDo you suffer for vascular insufficiency? *YesNoNotes:I accept to share any personal information, related to my health and personal lifestyle *AgreedPreviousSubmit
