Copy of опрос

Full Name

e-mail

Mobile Phone

City

Weight

Height

Age

Have you taken measurements of body measurements?

Yes

No

How often do you visit the dentist?

Once a year

Once in 6 months

Once a month

Only when i have a toothache

How often do you visit a gynecologist?

Once a year

Once every 6 months

Less than once a year

How often do you visit a urologist? (for male)

Once a year

Once every 6 months

Less than once a year

If there are delays in the menstrual cycle? (question for woman)

How long are the delays in the menstrual cycle? (question for girls)

Do you lead an active lifestyle?

Yes

No

I try but it doesnt work

How often do you workout?

once a week

two times a week

3 or more

less than 1 time per week

Are there any health restrictions?

Yes

No

Do you/(have you) worked out with a trainer personally?

Yes

No

Are there any injuries and medical contraindications?

Yes

No

Is your blood pressure normal?

Are you worried about pain?

Yes

No

Do you drink alcohol?

1 glass per week

2 or more glasses per week

more than 2 glasses per week

I dont drink alcohol

How would you rate your nutrition?

I try and do everything

Often there are breakdowns

limit myself

I eat intuitively

Have you used FatSecret or MyFitnessPal before?

Yes

No

Do you have allergic reactions to products?

Yes

Not

Difficult to answer

Do you often feel bloated or uncomfortable after eating?

Yes

Not

Difficult to answer

How often do you have a bowel movement during the day?

Less than 1 time

Once

2 times

2 or more times

What would you change in your diet?

What do you like more: flour, fatty, sweet, spicy, salty?

Are you following your diet?

I count and record kcal

Weigh all food

I eat intuitively

I dont control

How many meals per day?

Satisfied with your weight and shape? (write in detail)

What would be changed in the planned form? (write in detail)

Describe how your unhealthy behavior affects you on a daily, weekly, and monthly basis. What long-term results do you think your behavior will lead to?

How might your working life (or productivity) improve if you change (achieve the goal)?

If you failed once on this change, does that mean you failed?

Do you drink vitamin complexes?

Yes

Not

Sometimes

Do you take any medications or dietary supplements? (if yes, please specify)

Are you taking hormones? (If yes, please specify)

In the next 6-12 months, did you take blood biochemistry?

Specify your activity type

Level of physical activity during the day? (detailed)

Sports background (since childhood)