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General data

Name

Last name

Email

Phone

Patient age

Referred by

Eating habits (regular diet, vegan, vegetarian, etc.)

Tobacco use

Yes

Not

Alcohol consumption

Yes

Not

Level of physical activity (regular exercise, practice some sports, sedentary lifestyle, etc.)

Stress level (high, moderate, garlic)

Sleep quality (good, average, poor)

Consumption of current food and vitamin supplements

Detailed description of the symptoms or diagnosis if you have a current one

Duration of symptoms

Factors that aggravate or alleviate symptoms

Impact of symptoms on daily life

Thank you for your query, we will respond to you shortly by email or Whatsapp..

info@nnprotect.com.mx

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