Form Dietalog Online 2.3
Personal data
Name
Surname
Age
Sex
Female
Male
Profession
Email Address
Address
Location
Country
Zip code
Phone
Mobile phone
Anamnesis
Actual weight
Kg
Weight to 20 years
Kg
Desired weight
Kg
Actual height
cm
Abdominal circumference
cm
Wrist circumference
cm
Physique
Slim
Robust
Current pathologies of physical or psychological nature
Any recent analyzes. Specifying values outside the norm
Current drugs you are taking (indicate the reason of the assumption)
You indicate any problems of constipation, gastritis, slow digestion or other problems of the digestive system
You have dental amalgams, fillings?
YES
NO
Pressure
Normal
Hypertensive
Hypotensive
Menopause or hormonal problems?
YES
NO
Sometimes
Do you play any sports?
YES
NO
Sometimes
Which sport do you practice?
Feeding
Generally what do you eat for breakfast?
Generally what do you eat for lunch?
Generally what do you eat for dinner?
Unpleasant foods
Do you suffer from food allergies?
YES
NO
I do not know
Which foods are you allergic to?
Do you make snacks between meals during the day?
YES
Salty
Sweets
Both of them
NO
How many liters of water do you drink during the day?
How many teaspoons of sugar do you consume during the day? (for example in coffee, tea, etc.)
Do you drink sugary drinks?
YES
NO
Do you drink alcohol?
YES
NO
Relationship with yourself
Do you have a good relationship with your body?
YES
NO
Sometimes
Are you an insecure person?
YES
NO
Sometimes
Do you often get angry?
YES
NO
Sometimes
Do you live in stress?
YES
NO
Sometimes
You feel more
Extrovert
Introvert
Depends
Do you often cry?
YES
NO
Sometimes
Relationship with your parents (even past)
Excellent
Enough
Bad
How do You perceive your future (1 bad - 10 excellent)
1
2
3
4
5
6
7
8
9
10
Comments and notes on your character
Trichology
State of health of the hair
Thinning
Greasy hair with dandruff
Seborrheic dermatitis
Flaking of the scalp
Inflammation of the scalp
Information pursuant to Legislative Decree n. 196/2003 on the protection of personal data
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Informed consent
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