Questionnaire

Personal Information

Medical History & Nutrition Related Questions

  • Anemia
  • Anxiety or Chronic Panic Attacks
  • Arthritis (osteoarthritis or rheumatoid)
  • Asthma
  • Bronchitis
  • Cancer
  • Chronic Fatigue Syndrome
  • Prediabetes
  • Diabetes Type 1
  • Diabetes Type 2
  • Gestational Diabetes
  • Epilepsy
  • Fibromyalgia
  • Gout
  • Heart Attack
  • Heart Disease
  • Hepatitis
  • High Blood Fats (cholesterol/triglycerides)
  • High Blood Pressure
  • Hypoglycemia
  • Yes
  • No
  • sedentary (1-2 hours a week)
  • moderately active (3-5 hours a week)
  • active (6-7 hours a week)
  • athlete (8 hours or more a week)
Health and well-being are directly influenced by their nutrition and vice versa. By completing this form you accept that all mentioned information is correct and that you are accepting a treatment that is prepared based on the provided data. Any health condition occurred by a lack of information that is triggered due to the provided diet will be on customers' responsibility.