QUESTIONS.
NAME:
SURNAME:
ADRESS:
STREET:
CP:
TOWN:
Country:
MAIL:
SEX:
Woman
Man
CUT:
AGE;
0 to 10
10 to 20
20 to 30
30 to 40
40 to 50
50 and more.
Weight:
Waist measurement
Hip measurement:
Profession:
Ridges you of the sport?
yes
not
If So which?
Of diabéte?
yes
not
So yes of which type?
Of cholesterol?
yes
not
not Which rate?
Comments:
Use greasy substances:
yes
not
Which?
Eat meat?
yes
not
seldom
In which quantity?
Fish?
yes
not
seldom
In which quantity?
Eggs?
yes
not
seldom
Eat green vegetables?
yes
not
Once per day
Quantity?
Fresh fruits?
yes
not
Each day
Of the products laitiers?Lesquels?
Drink wine or another alcohol?
yes
not
seldom
In which quantity?
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Bonds:
Banner page.
Relieving.
Constipation.