Survey
Survey for checkout
By completing our questionnaire, you enable us to offer you the best service.
General information
First name
Surname
e-mail
Date of birth
Gender
Male
Female
Other (not specified)
Physical data
Body weight (kg)
Size (cm)
Lowest weight in the last 2 years
Highest weight in the last 2 years
Has your appetite changed recently?
Increased
Sunk
Unchanged
How much weight have you gained in the last 3 months?
How many kilos have you lost in the last 3 months?
Health information
Do you have a medically diagnosed health disorder?
Do you have allergies/intolerances to certain foods?
Are there any foods that cause you discomfort?
Do you have digestive problems?
Are you taking medication prescribed by a doctor?** Name of medication
Do you take dietary supplements?
Lifestyle habits
Do you smoke?
Do you consume alcoholic beverages?
Yes
No
Do you exercise regularly?
Eating habits
Do you skip meals?
Yes
No
If your answer is "Yes" or "Sometimes", which meal do you usually skip?
Breakfast
Lunch
Dinner
Snack
How many glasses or liters of water do you drink every day?
Daily coffee consumption
Daily tea consumption
Consumption of carbonated drinks
Sugar in daily drinks
Zero
Little
Medium
Much
Sweetener consumption
Zero
Little
Medium
Much
Diet and nutrition programs
Have you ever followed a diet/nutrition program?
From which expert have you received help with a diet/nutrition program so far?
Goals
Target weight
Do you consciously eat less than you would like?
Yes
No
Do you have binge eating episodes where you are not hungry (eat a lot in one episode)?
Yes
No
Do you have a habit of eating before going to bed?
Yes
No
Do you have a habit of waking up and eating at night?
Yes
No
How many hours do you sleep?
When do you go to bed?
When do you get up?
Sending
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