Nutrition Check Sheet
Please answer the simple questions.
What are you interested in? (multiple answers allowed)
I want to get well.
I want to get nice skin/teeth.
I want to know good supplement.
I want to know healthy life style/food.
I want to sleep well.
I want to wake up with feeling good.
I want to improve job concentration.
I want to avoid having a cold.
I want to loose weight.
I want to get back/keep my youth.
I want to avoid hangover.
I don't want to have a migraine/headache.
I want to reduce cramps.
I want to help constipation.
When do you brush your teeth?(multiple answers allowed)
after wake up
before go to bed
How long does it take when you brush your teeth?
within 3 min
over 10 min
Do you use cleaning devices except toothbrush?
Do you have any diagnosed disease?(multiple answers allowed)
High Blood pressure
digestive system disease
How many kinds of medicine do you take?
Which supplements do you take if you do?(multiple answers allowed)
Do you smoke?
used to smoke
To smokers, How often do you smoke a week?
How long do you sleep usually?
Less than 3 hours
over 10 hours
How many times do you eat in a day?
About Appetite(multiple answers allowed)
Feel hungry soon after eating
Don't feel full
Anytime thinking the meal (even had the meal)
Tend to eat too much
Hunger wakes you up
Dream about foods
Don't have an appetite
Get full very fast
Indigestion after eating
Don't feel good after taking protein/lipid
I eat very often...(multiple answers allowed)
Foods in convenience store
How much do you take some Water?
Less than 500ml
What kind of drinks do you take often?(multiple answers allowed)
Soda with sugar
Coffee with sugar
Black Tea with sugar
Vinegar drink(Black/Apple etc...)
Alcohol with sugar
What kind of food do you take often?(multiple answers allowed)
Do you drink alcohol?
How often do you take alcohol a week?
How often do you take some sweets a day?
4 times more
When do you feel like taking some sweets a day?(multiple answers allowed)
It depends on a day
How often do you take some fruits a day?
4 times more
Kindly pick out relevant parts of your mouth condition.(multiple answers allowed)
Have a cavity
Have a canker sore
Have sore of my tongue
Less sense of my taste
Cold drinks make your tooth hurt
Kindly pick out of clench and grind your teeth.(multiple answers allowed)
Dull chin/jaw and shoulder when you wake up
Teeth mark on your cheek or tongue
There is a gap between teeth and gums
Sometimes feeling wrong or pain of jaw joint
There is a tooth mobility
I dream the food in the early morning
There is a stripping tooth tip
The born is coming out slightly in your mouth
Sleepy at noon or evening
Please tell me about you.(multiple answers allowed)
I usually feel stressed.
It's hard to eat greasy.
I sometimes take stomach medicine.
I have a nightmare.
I don't feel refreshed after sleeping.
My concentration doesn't last so long.
I sometimes feel depressed.
I feel dizzy/sleepy in the afternoon/evening.
My nails are easy to be cracked.
I sometimes have a leg cramp.
I have something wrong on my throat.
I don't like pimples/spots on my face.
I have a cold easily.
I feel sleepy in the afternoon.
I wake up to go bathroom during sleeping.
I sometimes feel irritated.
I have diarrhea very often.
I repeat diarrhea and constipation over and over again.
I always have constipation. (I can't have a bowel movement so often.)
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