Personal Information
Date of birth
GenderMaleFemaleLGBTQ+ Relationship StatusSingleMarried BloodtypeA+A-B+B-AB+AB-O+O-Not sure What is your medical concernRejuvenation and anti-ageingBone and joint problemsLung diseaseHeart diseaseChronic disease (DM, HT)Hormone and sexualityEyeRespiratoryImmune disorder and inflammatoryInjury and accidentNeurologicalDigestive systemWeight managementOther (please specify)
Do you get sick often?YesNo Do you have any concerns about your skin or hair?YesNo Do you have any concerns about aging?YesNo Do you have any change in your libido?YesNo
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 systems such as bloating, cramping, constipation or diarrhea?YesNo
How many times 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 1-10?12345678910
Do you have any brain fog or memory issues?YesNo How would you rate your stress recently? 0-1012345678910
I have traveled to such countries:YesNo
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