Nutrition and lifestyle analysis

Personal information

Your name: *
Your surname: *
Your middle name: *
Phone number: * The phone number must be real, it can be used to contact you to clarify the missing information	Enter number using format: 380123456789
Email: * Be careful when filling out the email, after filling out the form, this mailbox will need to be confirmed

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Personal data

Weight: *	Kg.
Height: *	Cm.
Year of birth: *
Sex: *	Male Female
Waist circumference:	Cm.
Chest volume:	Cm.
Hips volume:	Cm.
Arm bicep volume:	Cm.
Hand volume:	Cm.
Leg volume:	Cm.
Occupation, activity category: *
Chronic diseases Hypertension, diabetes mellitus, food allergies, gastritis ...
Relatives chronic diseases: Diabetes mellitus, obesity, hypertension ...
Physical activity degree:
What result do you want to achieve: * Lose weight, get better ...

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Lifestyle analysis

Please answer "Yes" or "No" if you experience the indicated state / sensation.

Lack of energy, loss of strength: *	Yes No
Frequent illnesses: *	Yes No 4 or more times a year
Bad body and / or breath odor: *	Yes No
Digestion difficulties: *	Yes No
Frequent consumption of meat with blood: *	Yes No
Painful, irregular periods: *	Yes No
Frequent use of antibiotics: *	Yes No
Frequent alcohol consumption: *	Yes No
Frequent mood swings: *	Yes No
Food allergies: *	Yes No
Puffiness under the eyes: *	Yes No
Smoking: *	Yes No
Absent-mindedness, poor memory: *	Yes No
Lowered immunity: *	Yes No
Heartburn and gas after eating: *	Yes No
Frequent stress: *	Yes No
Skin problems or poor complexion: *	Yes No
Excessive carbohydrate intake, cravings for sweets: *	Yes No
Excessive consumption of dairy products: *	Yes No
Decreased mood, depression, apathy, depression: *	Yes No
Insomnia / restless, insufficient sleep and rest: *	Yes No
Problems associated with menopause: *	Yes No
Frequent urination: *	Yes No
Hair loss: *	Yes No
Swelling and joint pain: *	Yes No
Difficulty maintaining a healthy weight: *	Yes No
Fatigue: *	Yes No
Non-compliance with diet, poor nutrition: *	Yes No
Slow recovery: *	Yes No
Irregular bowel movements: *	Yes No
Lack of appetite (poor appetite): *	Yes No
Low sexual activity: *	Yes No
Thinned and brittle nails: *	Yes No
Dry, damaged dull hair: *	Yes No
Eating fatty foods: *	Yes No
Feelings of fear, anxiety: *	Yes No
Lack of fiber in the diet: *	Yes No Fiber is a plant food
Muscle cramps / spasms: *	Yes No
Unfavorable ecology: *	Yes No
Excessive consumption of tea, coffee: *	Yes No
Increased irritability: *	Yes No
Hypersensitivity to chemicals, food additives: *	Yes No
Yeast, fungal infections: *	Yes No
Weakness in muscles, fragility of bones: *	Yes No
Constant anxiety: *	Yes No
Excessive excitability: *	Yes No
Sedentary lifestyle: *	Yes No
Increased sputum production: *	Yes No

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Nutrition analysis

Number of main meals per day: *
Number of snacks per day: *
The amount of liquid you drink per day: *	L.
Of these, pure water: *	L.
List of dishes / foods that you usually eat for breakfast: Each on a new line
List of dishes / foods that you usually eat for lunch: Each on a new line
List of dishes / products that you usually eat for dinner: Each on a new line
List of meals / foods that you usually eat for a snack: Each on a new line
Favorite food / food list: 5-10 pieces. Each on a new line
List of Dislikes / Foods: Each on a new line
List of products / dishes for which you have contraindications: Each on a new line

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