Personal Information
Date of birth
GenderMaleFemaleOther Marital StatusSingleMarriedDo not Disclose
Blood typeA+A-B+B-AB+AB-O+O-Not sure
Last medical check-up?
How often do you consume alcoholic beverages?EverydayThree to four times a weekOnce or twice a weekOnce or twice a monthNever
Are you a smoker?YesNo
After diet – Do you have any digestive symptoms such as?
bloatingcrampingconstipationdiarrheanone
How often do you exercise?EverydayThree to four times a weekOnce or twice a weekOnce or twice a monthNever
After exercise – Do you have any concerns with your recovery from exercise?YesNo After exercise – Do you have any injuries or pain?YesNo How is your pain on a scale from 0-10?012345678910
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