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Diagnostic questionnaire

This questionnaire is a preliminary diagnostic tool which must be completed before your consultation, with total confidentiality guaranteed. It is important that you answer as accurately and completely as possible.

The expected completion time is 20 minutes.

Diagnosis
What is the primary purpose of the consultation?
How did you hear about MetaClinic?
cm
kg
Do you have children?
Menstrual cycle
Do you use any contraceptive method or hormone regulator?
Do you suffer from polycystic ovary syndrome?
Usual premenstrual symptoms
Do you have breast implants?
Breast prostheses influence the assessment of body composition by biompedance and is a factor to be taken into account in the analysis.
Do you suffer from any of these diseases or dysfunctions?
Direct family history of the disease.
Do you currently have a smoking habit?
Have you been a smoker in the past?
Indicate the average number of hours of sleep per night.
Do you work night shifts?
Do you have trouble falling asleep?
Do you have trouble staying asleep?
1 being very bad, and 5 being very good.
1 equals very little, and 5 equals a lot of energy.
1 equals very little, and 5 equals a lot of energy.
1 equals very little, and 5 equals very good.
1 equals very little, and 5 equals very anxious.
Are you prone to depression?
1 equals very little, and 5 equals very good.
1 is very low and 5 is very high.
Do you have postural breaks from tension (orthostatism)?
1 equals none, and 5 equals very sensitive.
Indicate the strength of your nails.
Do you have weak, brittle or prone to hair loss?
Is your intestinal transit regular?
Do you feel a growing abdominal bloating throughout the day?
Have you been diagnosed with gastritis or gastric reflux?
1 equals very little, and 5 equals a lot of appetite.
Do you feel a big increase in appetite at the end of the day?
Do you wake up hungry?
Do you suffer or have you ever suffered from an eating disorder?
1 equivale a muito pouco, e 5 a totalmente.
Indicate your average daily water consumption.
Indicate your average daily coffee consumption.
Indicate your level of alcohol consumption.
Do you take any food supplements?
Do you or have you ever taken anabolic steroids or other illicit substances for hypertrophy or weight loss?
Indicate which ones.
Do you practice structured physical exercise?
How often do you train each week?
Indicate the sports you do.
Do you train with a personal trainer?
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