Men's questionnaire

This is a free questionnaire. Fill it out and I will contact you for a consultation.

* — required fields

General Information

Name *

Last Name *

Age *

Height *

Weight *

Weight Goals

Are you satisfied with your weight?

How many kg do you want to lose / gain *

Water Intake

How many liters of pure water do you drink per day? (not counting tea, coffee, juices and other drinks)

Hair

Hair condition

Teeth and Gums

Teeth condition

Digestion

Check what applies

Gallbladder and Kidneys

Operations and Injuries

Blood Pressure

Blood pressure

Do you take medication and for how long? *

Chronic and Autoimmune Diseases

Check what applies

Nervous System

Check what applies

Circulation

Check what applies

Vessels and Skin

Vessel condition

Skin condition

Joints and Spine

Formations

Check what applies

Infections and Discharge

Check what applies

Prostatitis

Is there prostatitis or problems with urination

Skin

Check what applies

Allergies

Check what applies

Colds

How often do you get sick per year

Do you use antibiotics or antipyretics

Sleep

Check what applies

Energy

Check what applies

Memory and Concentration

Check what applies

Lifestyle

Check what applies

Contact with toxic substances (specify) *

Medications

Do you take medications on a regular basis (specify) *

Supplements

How do you take them?

Tests and Examinations

Do you have blood test results from the last 2–3 months or did you have ultrasound

Attach files with test results and examinations

Choose files

Multiple allowed. PDF, JPG, PNG, DOC, DOCX, XLS, XLSX. Up to 10 MB each.

Additional

What else would you like to add about your health *

How did you learn about me?

How to reach you *

Choose a convenient method and enter your contact