1. How often do you visit your doctor for a problem?

2. Have you been diagnosed with:
Heart Problems (Hypertension, Coronary Artery Disease)Thyroid DiseaseStrokeLimb ThrombosisHormonal ProblemsKidney DiseasePulmonary DiseaseNeurological DiseaseLiver DiseaseIrritable Bowel SyndromeBronchial AsthmaAllergies

3. Please state any other diseases:

4. Do you have obesity? NoYesMaybe

5. Do you smoke?
NoYes

5.1 If Yes, how many cigarettes?

5.2 And for how long?

6. Is your daily activity intense?
NoYes

7. Do you feel fatigue?
NoYesMaybe

8. Please state if you receive any medicines or supplements

9. What bothers you more?

10. What has changed in your daily routine?

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