Questionnaire for appointment for consultation
Health Survey for Recommended Tests
After completing the questionnaire, you will receive a personalized list of tests to complete before your consultation, ensuring our appointment is effective and productive.
Begin
I have read and agree with the contract of public offer for the provision of remote information services
Your contact information:
Your age
Up to 18 years old
18-30 years
31-50 years
Over 50 years old
Your gender
Man
Woman
Your height (cm)
Your weight (kg)
What's bothering you?
Select one or more options
Weight gain
Difficulty losing weight
Weakness or fatigue during the day
Trouble falling asleep at night or waking up in the morning
Cold hands and feet, even in warm weather
Hot flashes or sudden changes in body temperature
Mood swings
Decreased libido
Constant thirst
Frequent urination, especially at night
Feeling unusually cold or hot
Memory or concentration issues
Anxiety or irritability
Hair loss or brittle nails
Dry or itchy skin
Abdominal bloating or swelling
Joint pain or muscle weakness
Menstrual irregularities (for women)
My own option
*Select one or more options
Have you been diagnosed with any chronic illnesses?
Select one or more options
Diabetes
Hypothyroidism (underactive thyroid)
Hyperthyroidism (overactive thyroid)
Polycystic Ovary Syndrome (PCOS) (for women)
High blood pressure
High cholesterol
Anemia (low hemoglobin or iron)
None
My own option
*Select one or more options
Your eating habits:
Select one or more options
I eat 3 meals a day without snacking
My meals are irregular
I snack frequently throughout the day
I follow a specific diet (e.g., low-carb diet)
I consume a lot of sweets or fatty foods
I usually have a late dinner around 9-10 p.m.
My own option
*Select one or more options
What kind of physical activity do you practice?
No physical activity
Light walking
Regular exercise (2-3 times a week)
Intense activity (4 or more times a week)
My own option
*Select one or more options
Do you take any medications or supplements?
Yes, regularly
Yes, occasionally
No
If yes, please provide the names
*Select one or more options
What is your main goal?
Select one or more options
Lose weight
Achieve a healthy, energetic body
Feel light and active throughout the day
Improve sleep and reduce fatigue
Balance hormones for better overall health
Address skin and other aesthetic concerns
Enhance concentration and mental clarity
My own option
*Select one or more options
Next
Find out the result