Pre-questionnaire

LOLU™ HEALTH Diet Assessment Questionnaire

Homework before the 1st appointment of LOLU™ HEALTH diet plan

Complete the form and let us start personalizing your diet to reach your health goal!

We take your privacy seriously and ensure that all information collected will be kept strictly confidential.

*Please check the Terms of Service, the Privacy Policy, and the Agreement of Participation and Confidentiality.

*

I have read and accept the conditions of the Terms and conditions and the Privacy policy*

I agree to the Agreement of Participation and Confidentiality Your agreement below indicates your permission and willingness to participate in the below assessments, questionnaires, and interviews and consider the potential program or recommendations, including interviews, counselling, nutrition therapy, personal training sessions, and subsequent dietary/nutrition/exercise/health recommendations. All information and data discussed, written, typed, or communicated will be strictly confidential between the patient and the LOLU™ HEALTH team. You agree that the information you provide in the forms, assessments, and interviews is accurate and current to the best of your ability. The LOLU™ HEALTH team commits to helping you reach your goals, encouraging and motivating you to overcome obstacles, equipping you to make healthy decisions, and not giving up on you or your goals. You also acknowledge that LOLU™ HEALTH team is not solely responsible for your complete healthcare and needs to understand and be made aware of any changes or concerns in your health.

First Name *

Last Name *

Email *

Preferred day of 1st diet assessment : *

Please allow 1 week from today

Preferred time: *

We will contact you to confirm the time

Your country *

Please select one

What is your age (year)? *

Your sex

How tall are you (cm)? *

Your waist circumference (cm)? *

Your hip circumference (cm)? *

What is your weight (kg)? *

What's your diet goal?

Choose your daily activity level: *

Are you pregnant or trying to get pregnant? *

Are you taking oral contraceptives? *

Do you use tobacco? *

Do you use any controlled substances? *

Do you have any allergies? *

If have any allergies, please specify.

If you or a blood relative have been diagnosed with or experienced thyroid problems, please specify the condition and the medication.

If you or a blood relative have been diagnosed with or experienced cardiovascular problems or hypertension, please specify the condition and the medication.

If you or a blood relative have been diagnosed with or experienced lung problems, please specify the condition and the medication.

If you or a blood relative have been diagnosed with or experienced bone problems, please specify the condition and the medication.

If you or a blood relative have been diagnosed with or experienced oesophagus, stomach, duodenum, small intestine, large intestine, or rectum problems, please specify the condition and the medication.

If you or a blood relative have been diagnosed with or experienced liver problems, please specify the condition and the medication.

If you or a blood relative have been diagnosed with or experienced bile duct problems, please specify the condition and the medication.

If you or a blood relative have been diagnosed with or experienced bile duct or pancreatic problems, please specify the condition and the medication.

If you or a blood relative have been diagnosed with or experienced kidney problems, please specify the condition and the medication.

If you or a blood relative have been diagnosed with or experienced blood glucose or blood lipids/cholesterol problems, please specify the condition and the medication.

If you or a blood relative have been diagnosed with or experienced any health conditions that are not listed above, please specify the condition and the medication.

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