What’s your gender and age?
Age
What’s your height and weight?
Height
Weight
What’s your main health concern?
Health Concern
General Health Facial Skin Conditions Hair Problems Gastrointestinal Health Insomnia Migraine Dry Eyes Women’s Health Fatigue Anxiety/Depression
How frequent do you exercise?
Which of these represent your exercise routines?
What time do you normally sleep at night?
Sleep Time
7pm 8pm 9pm 10pm 11pm 12am 1am 2am 3am
How many hours do you normally sleep?
Do you feel weak or tired easily?
Do you speak softly, compared to your peers?
Do you get backache or weak knees?
Are you afraid of cold? What kind of facial issues do you face? Do you get allergies (hives, runny nose, etc) easily?
Do you fall sick easily, compared to others? Do you get bitter taste in mouth or feel thirsty? Do you get stressed or moody easily?
How many servings of vegetables you eat per day?
How many servings of fruits you eat per day?
How many servings of meat / protein you eat per day?
How many servings of carbohydrates you eat per day?
Which best describes your favourite food?
How often do you take cold food (salad, sashimi, iced drinks)?
How many glasses (200ml) of water you drink per day?
Your Name*
Email Address*
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