Questionnaire
The Program is designed to support health and our doctors do not advise in cases of chronic or acute diseases, critical conditions, nor they consult children under 18.
Sign in to Google to save your progress. Learn more
Full name *
Sex *
Date of birth *
MM
/
DD
/
YYYY
Phone number *
Which messenger is more convenient for contact? *
Do you have any allergiеs (medications, food allergies)? *
Required
Are you intolerant to any medications, herbs or dietary supplements? *
Do you now have a history of cancer? (If so, indicate when and what exactly) *
What serious diseases have you suffered in the last 2 years? *
The recent stress has had a profound effect on me. *
I'm scared and anxious, even if I'm in a relatively safe place. *
It often seems to me that something bad is about to happen and I have restless thoughts for no objective reason. *
Sometimes I have a fast heartbeat for no objective reason. *
Things don’t bring the same level of joy as before. For example, I can't enjoy a cup of coffee like I used to. *
I often have a depressed and apathetic mood, regardless of the news. *
I pay less attention to my appearance and less often smile even at the good news. *
I have a tendency to depression *
I have decreased tolerance for stressful situations *
I've been feeling annoyed lately; I am very annoyed even by a slight noise *
It is difficult for me to fall asleep even in silence and relatively comfortable conditions *
I wake up at night without external influences (air raid sirens, loud sounds) *
A night's sleep does not bring vigor and it is difficult for me to get out of bed in the morning. *
After sleep I have a slightly hoarse voice. *
Lately I work a lot and hard, I get tired and almost do not rest *
Lately I’ve become less productive at work *
My thinking has slowed down, I make mistakes when I'm in a hurry or under pressure *
My mental processes and mental acuity have decreased significantly *
Recently, my memory has deteriorated significantly *
 I have a bad memory for recent events *
Lately it has become difficult for me to concentrate on current tasks *
I had self-doubt and weak motivation to act *
I often feel weak and drowsy in the afternoon *
I constantly feel very tired, it does not pass even after a night's sleep *
When I rise sharply from a horizontal position, I feel dizzy *
Sometimes I feel that I’m going to loose consciousness for no objective reason *
I have a tendency to hypotension (low blood pressure *
I get tired quickly from physical exercises *
I noticed that I became less sweaty even with intense exercise *
I often have sore muscles and joints *
Recently, the mobility of my joints has decreased significantly *
My muscles have lost tone, strength and elasticity *
Recently, the amount of my muscle mass has decreased, and fat, on the contrary, has increased *
I have difficulty losing weight *
I am prone to rapid weight gain *
I have a tendency to deposit fat in the abdomen *
Recently, I have developed fat deposits in the chest and thighs *
I have digestion problems when I am in a stressful situation *
I have a tendency to constipation (stool less than once a day) *
I have high blood cholesterol *
I often suffer from SARS and ARI, feel under the weather *
I have had frequent allergic reactions that I did not have before *
I have an intolerance to low temperatures *
I often have cold feet and hands *
My ankles sometimes swell and the swelling worsens in the evening *
I have swelling of the face and eyelids in the morning *
Recently, my skin has become drier and needs intense hydration *
Recently, I’ve noticed that my mucous membranes are less moisturized *
Recently, my skin has become thinner and less elastic *
Lately I've been losing a lot of hair on my head *
Recently, the amount of my body hair has decreased *
The outer part of my eyebrows is thinner than the middle or inner part *
Recently, my libido has decreased and I’m experiencing some difficulties in achieving sexual pleasure *
Women
I have a menstrual disorder
Clear selection
I am pregnant / lactating
Clear selection
Men
I have abnormalities in the prostate gland (frequent nocturnal urination, urinary retention, incomplete bladder emptying, diagnosed prostatitis or prostate adenoma, etc.). If so, please specify.
Clear selection
Recently, I may have difficulty getting an erection during intercourse
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms