Name *

E-Mail *

Weight *

Size (cm) *

Age *

Highlight the diseases you have. * DiabetesHypertensionHeart DiseaseInsulin ResistanceAsthmaSnoringSexual problemsGastritis

Has a psychiatric diagnosis been made for drug or alcohol addiction? * YesNo

Please write down your chronic illnesses or other illnesses. *

Do you smoke? (Answer after the last 3 months.) * Yes half a pack a dayYes one pack a dayYes more than one pack a dayNo I don’t use

Please indicate the medications you take regularly. *

Have you been trying to lose weight for a long time? * YesNo