Role Models List

Questionnaire

Customer Data & Address 1/5

Activity & Eating Habits 2/5

Diagnosis 3/5

Medications & For Woman 4/5

Physical Condition 5/5

Customer Data

First Name *

Last Name *

HOW DO YOU WANT US TO CONTACT YOU?

EMAIL PHONE SMS

EMAIL *

PHONE *

DATE OF BIRTH *

Select your birth date

GENDER *

FEMALE MALE

HEIGHT *

CM FT / IN

WEIGHT *

KG LBS

Address

STREET *

HOUSE NUMBER *

POSTAL CODE *

CITY *

COUNTRY CODE *

CHANGE OF ADDRESS *

YES NO

Activity

HOW WOULD YOU BEST DESCRIBE YOUR OCCUPATION SITUATION? *

EXCLUSIVELY SEDENTARY OR LYING LIFESTYLE. EXCLUSIVELY SEDENTARY JOB WITH LITTLE OR NO STRENUOUS LEISURE ACTIVITY SEDENTARY WORK, OCCASIONALLY ADDITIONAL ENERGY EXPENDITURE FOR WALKING AND STANDING TASKS PREDOMINANTLY WALKING AND STANDING WORK PHYSICALLY DEMANDING PROFESSIONAL WORK

HOW OFTEN DO YOU ENGAGE IN SPORTS OR OTHER STRENUOUS ACTIVITIES (LONGER THAN 30 MINUTES) PER WEEK? *

NEVER 1-3 TIMES 4 OR MORE TIMES

Eating Habits

HOW OFTEN DO YOU CONSUME MEAT?

NEVER RARELY REGULARLY DAILY DAILY MUCH VERY MUCH

HOW OFTEN DO YOU CONSUME FISH?

NEVER RARELY REGULARLY DAILY DAILY MUCH VERY MUCH

HOW OFTEN DO YOU CONSUME EGGS?

NEVER RARELY REGULARLY DAILY DAILY MUCH VERY MUCH

HOW OFTEN DO YOU CONSUME DAIRY PRODUCTS?

NEVER RARELY REGULARLY DAILY DAILY MUCH VERY MUCH

HOW OFTEN DO YOU CONSUME FRUITS, SALADS, OR VEGETABLES?

NEVER RARELY REGULARLY DAILY DAILY MUCH VERY MUCH

Eating Habits

HOW MUCH LIQUID DO YOU DRINK PER DAY?

LESS THAN 1 LITER 1-2 LITERS 2-3 LITERS MORE THAN 3 LITERS

DO YOU CONSUME ALCOHOL? (1 GLASS OF WINE = 0.2 LITERS, 1 GLASS OF BEER = 0.5 LITERS)

NEVER RARELY ONE GLASS DAILY 2-3 GLASSES DAILY MORE THAN 3 GLASSES A DAY

DO YOU SMOKE? IF YES, HOW MUCH?

NO LESS THAN 10 CIGARETTES PERDAY 1 PACK PER DAY MORE THAN 1 PACK PER DAY MORE THAN 2 PACKS PER DAY

IS SMOKING COMMON IN YOUR ENVIRONMENT? *

YES NO

DO YOU SUFFER FROM ANY ALLERGIES OR INTOLERANCES? *

NO GLUTEN MILK, DAIRY PRODUCTS FRUITS IN GENERAL CITRUS FRUITS IODINE POLLEN, HAY FEVER, ETC. SEAFOOD, SHELLFISH COPPER HISTAMINE ESSENTIAL OILS

Diagnosis

DO YOU SUFFER FROM CONSTIPATION?

NEVER RARELY (ALMOST) ALWAYS

DO YOU SUFFER FROM DIARRHEA?

NEVER RARELY (ALMOST) ALWAYS

HAVE YOU HAD RECURRING STOMACH IRRITATION OR ULCERS? *

YES NO

DO YOU SUFFER FROM RECURRING HEARTBURN? *

YES NO

HAS CANCER THERAPY BEEN COMPLETED? *

YES NO

COULD STRENGTHENING YOUR IMMUNE SYSTEM HAVE NEGATIVE CONSEQUENCES? *

YES NO

DID YOU RECEIVE A COVID 19 VACCINATION? *

YES NO

DO YOU HAVE LIBIDO PROBLEMS? *

YES NO

Diagnosis

DO ANY OF THE FOLLOWING CONDITIONS APPLY TO YOU?

ACNE ALZHEIMER'S, DEMENTIA ARTERIOSCLEROSIS OSTEOARTHRITIS (JOINT WEAR AND TEAR) BRONCHITIS (BRONCHIAL) ASTHMA BLOOD LIPID METABOLISM DISORDER (HYPERLIPOPROTEINAEMIA) HIGH BLOOD PRESSURE BURNOUT SYNDROME CHRONIC FATIGUE SYNDROME BOWEL DISEASES (CROHN'S DISEASE, ULCERATIVE COLITIS (IRRITABLE BOWEL SYNDROME)) DEPRESSION TYPE 1 DIABETES TYPE 2 DIABETES INFLAMMATORY DISEASES (E.G.,RHEUMATOID ARTHRITIS) EPILEPSY FREQUENT COLDS FIBROMYALGIA (TENDON, MUSCLE PAIN) HEART DISEASE GASTRITIS (CHRONIC HELICOBACTER PYLORI INFECTION, GASTRITIS) HAIR LOSS, BRITTLE NAILS HERPES (SIMPLEX: COLD SORES, ZOSTER: SHINGLES) CARDIAC ARRHYTHMIA CANCER (ACUTE, UNDER TREATMENT) HYPERACTIVITY (LEARNING AND CONCENTRATION DISORDERS, ADD, HYPERKINETIC SYNDROME) CARDIAC INSUFFICIENCY LONG COVID MACULAR DEGENERATION,AGE-RELATED MIGRAINE MULTIPLE SCLEROSIS (MS) NEURODERMATITIS OSTEOPOROSIS PERIODONTITIS KIDNEY DISEASE (RENAL INSUFFICIENCY OR OTHER KIDNEY DISEASE, CHRONIC OR ACUTE) PARKINSON'S PSORIASIS POTENCY PROBLEMS (ERECTILE DYSFUNCTION) THYROID DISEASE (HYPERTHYROIDISM) TINNITUS (RINGING IN THE EARS) CELIAC DISEASE

Medications

PLEASE CHECK WHICH MEDICATIONS YOU REGULARLY TAKE:

Lipid-lowering drugs (cholesterol-lowering) Antidiabetics or Insulin (blood sugar-lowering) Antihypertensives (blood pressure-lowering drugs) Diuretics (water-excreting drugs) Blood thinners Hormones Anti-obesity drugs (weight reduction) Gout medications Antidepressants Parkinson's medications Stomach medication (acid blockers-PPI) Pain relievers

I REGULARLY TAKE OTHER MEDICATIONS NOT LISTED HERE:

MICRONUTRIENT PREPARATIONS:

OTHER MEDICATIONS:

WAS THE DOSAGE OF A MEDICATION OR SUPPLEMENT EVER REDUCED DUE TO A STRONG REACTION?

YES NO

For women

DO YOU HAVE MENSTRUAL PROBLEMS?

YES NO

DO YOU HAVE MENOPAUSAL SYMPTOMS?

YES NO

CYCLE DAY

01. TO 10. DAY 11. TO 17. DAY 18. TO 28. DAY

NO CYCLE

CHILD NO UTERUS DUE TO HORMONE THERAPY (PILL, MINI-PILL, VAGINAL RING, HORMONE PATCH, HORMONE COIL, ETC.) DUE TO PREGNANCY DUE TO BREASTFEEDING DUE TO THE MENOPAUSE (CLIMACTERIC, MENOPAUSE) DUE TO POSTMENOPAUSE (SENIUM)