CHECK-UP. Please fill in the following questionnaire as precisely as you can. Thank you! Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Country (###) ### #### Conditions that I had/have * Diabetes 1 Diabetes 2 PCOS Insulin Resistance Heart failure Cancer Gallstones Appendectomy Splenectomy Gallbladder removed Coronary stent Coronary baypass Fibromyalgia Celiac disease Kidney stones Grave's disease Addison's disease Hashimoto's disease Mastocitosis Multiple Sclerosis ALS Psoriasis Systemic Lupus Bell's Palsy Endometriosis Chron's disease Scleroderma IBS-c IBS-d Lactose intolerance Diverticulosis Acid Reflux GERD Ulcerative collitis IBD Histamine Hypothyreosis Hyperthyreosis Cholesterol Chronic EBV Lyme disease VZV AIDS Hepatitis B Hepatitis C Mycoplasma Pneumonie Tuberculosis Deep vein trhombosis Pulmonary hypertension Hypertension Hypotension Vitiligo Ezcema Seborrheic dermatitis Mercury Lead Nothing above Conditions not listed: Supplements * Vitamin A Vitamin B12 Vitamin D Vitamin K2 Vitamin B6 Pyridioxine Vitamin B1 Vitamin B Complex Vitamin C Vitamin E Magnesium Zinc Calcium Copper K2D3 Folic Acid B9 Mehtylfolate B9 Omega 367 Omega 3679 Omega 3 Omega 6 Omega 9 Omega 7 Iron Chromium Beta Caroten Coenzyme Q10 Biotin B7 Panthoteic acid B5 Niacin B3 Shilajit Iodine Probiotic Prebiotic Riboflavin B2 Beta Glucans Inulin Glucosamine Melatonine Selenium Multivitamin Fish Oil Curcumin Maca Gelatine Creatinine Whey proteine Other protein Beef Collagen Fish Collagen At the moment I take Allergies * No allergies Milk products Gluten Eggs Fish Strawberries Kiwi Raspberries Animals Cats Dust I often sneeze I often have red eyes I often have sinus infections I often have throat pain I have asthma I have migrains I have headaches I have ezcema I have dermatitis I have redness I have dark underyes Bees Wasps My face is swollen in the morning My eyelids are swollen in the mornin I ended up in ER because of my allergy I had angioedema Peanuts All nuts I often have stuffed nose Ambrosia House dust mites I often have watery eyes Antibiotic Penicilin Allergies not listed Skin * Dry Normal Oily Combination Dehydrated Hormonala acne Blackheads Whiteheads Cystic Acne Hypopigmentation Hyperpigmentation Vitiligo Rashes Psoriasis Redness Skin flaking I often have oral herpes (cold sores) I have many moles I never had herpes I have acne scars I have other scars I have saggy skin I have enlarged pores I have lot of wrinkles I have eye wrinkles I have wrinkles above my lips I have stretchmarks I have keloid scars I have cellulite I have lymphedema I have visible capillaries on my face I have visible capillaries on my body I have itchy skin I have spider veins I have scleroderma I have lupus I have rosacea I have uneven skintone I have pimples before my cycle I have new pimples every day I have new pimples every week I have new pimples monthly I never had oral herpes (cold sores) I have increased hair on my body Hair * Thin I am loosing a lot of hair I do not have hair I have alopecia I have hair transplant My hair is healthy My hair is oily My hair is dry My hair breaks easily I dye my hair Drugs * Controloc Nexium Cardiopirin Aspirine Besedine Propranolol Lorazepam Famotidine Eutyrox Fraxiparin Prednisone Pronisone Epica Roxera Pregabalin Lasix Canabis Roaccutan Brilique Heferol Clindasome Nitroglycerine Cycle * I have regular cycle I have irregular cycle I do not have cycle My cycle lasts more than 7days My cycle lasts less than 5 days I have premenstrual pain I have premenstrual depression I have menstrual pain I have ovulation pain I have visited gynaecologist in the past 12 months for ultrasound I have done breast ultrasound in the past 12 months I have cyclic breast pain I am in postmenopause I am a man Digestive issues * Gas Bloating Weight gain Weight loss Bulimia Anorexia Orthorexia Stomach pain Constipation Diarrhea Stress Lack of sleep Sitting more than 7 hours per day Burping Difficulty swallowing Cavity/Caries/Tooth decay I have 1 meal per day I have 2 meals per day I have 3 meals per day I have 4 meals per day I have 5 or more meals per day I eat almost whole day I eat after 8pm I eat after 10pm I eat as soon as I get up I drink 1l of water per day I drink 1.5l of water per day I drink 2l of water per day I drink more than 2.5l water per day I drink soda I drink fruit juices I drink energy drinks I eat sweets every day I lay in bed after 10pm I lay in bed after 12pm I get up before 8am I get up after 8 am I drink tea every day Skincare products I use at the moment: * I state that the information provided above are true and accurate. * Thank you! THANK YOU
