Questionnaire for LuckyFit LuckyFit » Questionnaire for LuckyFit QUESTIONNAIRE for LuckyFit Programme* StandardFULL DETOXAntistressPlusWeekend GENERAL QUESTIONS: Name and surname*: Age*: years Weight*: kg. Height*: sm. E-mail address*: Telephone number*: How did you find out about LuckyFit?* from friendsGooglefrom Aparthotel Lucky Banskoother What's the purpose of your participation in LuckyFit? (please choose one of the options) weight lossdetoxificationanti-stressyogagood timeI'm accompanying someoneAnother Is it your first time in LuckyFit?* YesNo – It is the second timeNo - more than two times Is this your first detoxification therapy?* YesNo How many times do you go through a detoxification therapy in a year?* 1234 Have you ever starved for healing purposes (even if for a day)?* YesNo Would you undergo a 36-hour starvation?* YesNo What part of your body would you like to cleanse?* The whole organismLiverSpleenBlood systemLymphDigestive system LIFESTYLE What food regime are you following?* Standard (including meat)VegetarianVeganAnother (Fill in the box) How many times a day do you eat? 12345 What kind of food do you not consume? Do you smoke? NoYesI smoke less than 10 cigarettes a day Do you drink alcohol? NoYesRarely LEVEL OF PHYSICAL TRAINING: How often do you do sport weekly? I do not trainI train 1-3 times a weekI train 3-5 times a weekI am athlete How would you define your physical shape and stamina? Readiness for light workouts.Readiness for moderate workoutsReadiness for intensive workouts Do you have any experience in mountain hiking? YesNoLittle HEALTH CONDITION – GENERAL QUESTIONS: Do you have any history of heart problems because of which your doctor has recommended you to perform physical activity only after medical consultation? NoYes Do you ever feel pain in the chest when performing physical activities? NoYes In the last month, have you felt pain in the chest when you are not performing physical activities? NoYesI dont'know Do you ever lose balance due to dizziness or lose consciousness? NoYes Do you have bone or joint problems (for example, back, knees or hip joints), which can worsen due to change in the physical activities? NoYesI dont'know Did you have your blood tested according to the list we had sent you? NoYes please attach them here or send them to info@luckyfit.eu Blood sugar level: Blood pressure: At the moment, are you taking any drugs for high blood pressure or heart problems? NoYes At the moment, are you taking any other drugs? NoYes please describe what kind: Did you have any serous trauma or surgery in the past two years? NoYes please describe what kind: Please mark “yes” in case you are pregnant specify in which month Can you name any other reason why it is not recommended for you to perform physical activities? NoYes please describe what kind: QUESTIONS RELATED TO DETERMINING OF THE DETOXIFICATION REGIME BY OUR DOCTOR-DIETOLOGIST: To determine the right way to do your detoxification treatment, you need to answer all of the questions below. Your answers will be processed by our doctor-dietologist and you will be prescribed an individual three-week detoxification regime. Note the presence (absence) of a symptom and its manifestation level. QUESTIONS: Meteorism (gas in the abdomen) or belching I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Burning behind the breastbone I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Swelling or discomfort shortly after food intake I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Bad breath I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Chronic diarrhea I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Chronic constipation I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Nausea and vomiting I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Unshaped stools I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Presence of undigested food pieces in the stools I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Feeling of weakness after intake of wine I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Feeling of intoxication after intake of a small quantity of alcohol I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Hangover from a small quantity of alcohol I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Sensitivity to smells (perfumes, paints, etc.) I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Sensitivity to tobacco smoke I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Discomfort after intake of the sweetener aspartame (NutraSweet) I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Chronic fatigue I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Irritability after coffee intake I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Strong feet smell I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Strong sweat smell I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Increased sweating I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Dark circles around the eyes I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Under-eye bags I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Increased urination (in frequency and quantity) I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Waking up at night to go to the toilet (to urinate) I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Frequent urinary Infections and cystitis I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Lithiasis (kidney stones) I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Morning swelling of the eyes I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Oily skin I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Dry scaling skin and/or dandruff I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Itching on the skin I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Brown spots on the hands and face I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Acne I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Eczema I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Frequent infections I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Sinusitis I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Prostatitis I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Manifestation of allergies as an adult I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Swollen nodes I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Headache I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Cellulite I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Overweight I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Lack of physical activity I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Sedentary way of life I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Work in an environment with dangerous chemical agents I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Asthma or bronchitis I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Hard breathing I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe Oxygen deficiency I've never had this symptomI sometimes have it but it is not severeI sometimes have it and it is severeI often have it but it is not severeI often have it and it is severe MEDICINE INTAKE: Antibiotics intake more than twice a year? YesNo Taking contraceptions for a long period (more than 6 months)? YesNo Permanent drug intake for more than 1 year? YesNo specify which Operation(s) with full anesthetic for the last five years? YesNo specify which Taking corticosteroids? YesNo Taking Hormones? YesNo specify which 2018-01-30
