1. How often do you consult your physician and for what reason?

2. Have you been diagnosed with :Cardiovascular diseases (hypertension, coronary disease)ThyroidopathyStrokeDeep vein thrombosisHormonal issuesKidney DiseasePulmonary DiseaseLiver DiseaseIrritable Bowel SyndromeAsthmaAllergiesPsychiatric DiseaseSkin Disease

3. Please mention any other diseases not listed above:

4. Do you suffer from any Immune system disease? NoYesMaybe

5. Have you ever been exposed to chemicals or toxic substances?NoYes

6. Do you smoke?
NoYes

6.1 If Yes, how many cigarettes?

6.2 And for how long?

7. Do you have intense physical activity?
NoYes

8. Have you recently noticed any change in your senses?
NoYes

9. Have you recently noticed any change in the way you walk or possible loss of stability?
NoYes

10. Have you recently noticed changes in your memory or memory gaps?
NoYes

11. Do you feel fatigue?
NoYes

12. Please mention any medications or supplements that you take

13. What is your main health issue?

14. Has your daily life changed and to what extend?

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