my daily cure - survey - ver. 0.53a

First Name *

Type your first name or nick name

Family Name

What is your family name

Your Age *

Date of Birth

Gender

Your biology is linked to your genetics

Male (Biological)

Female (Biological)

Other than Male/Female

Ethnicity

Your heritage could have a significant influence on your metabolism

African

African American

Asian / Asian American

Caucasian / White

Hispanic / Latino

Middle Eastern / North African

Native American / Indigenous

Pacific Islander

Mixed / Multiracial

Other

Prefer not to say

Your height in cm

It will help calculate your BMI for statistical recommendation

Your weight in kg

It will help calculate your BMI for statistical recommendation

Contact Number

+41 70 123 45 67

Email address *

john.doe@mypersonalemail.com

Prefered Language

Don't worry! We have performant AI tools to translate any question or send you the expected answer in your mother tongue if necessary

English

French

Dutch

German

Italian

Portuguese

Spanish

Russian

Ukrainian

Country

In which country do you leave, we must follow your local regulation.

Belgium

France

Germany

Greece

Ireland

Italy

Netherlands

Portugal

Russia

Spain

Switzerland

UAE

Ukraine

United Kingdom

Other

Marital Status

Don't feel obliged !

Single

Married

Divorced

Widowed

In a Relationship

Other

Occupation

Let's understand your life style and occupation

Targets for main Improvement Profile

General Health Support

Detoxification and Inflammation Reduction

Energy level Boost

Cognitive and Focus boost

Anti-Aging and Libido Support

Extreme Weight Loss

General Health Condition

Excellent

Good

Average

Poor

I am Not Sure

Chronic Conditions

Hypertension

Pre-diabetes

Type 1 Diabetes

Type 2 Diabetes

Cardiovascular and Heart Disease

High Cholesterol

Osteoporosis

Osteopenia

Arthritis (Rheumatoid) • Arthritis (Osteoarthritis)

Arthritis (Osteoarthritis)

Asthma

COPD (Chronic Obstructive Pulmonary Disease)

Hypothyroidism

Hyperthyroidism

Irritable Bowel Syndrome (IBS)

Inflammatory Bowel Disease (IBD, includes Crohn’s Disease, Ulcerative Colitis)

GERD (Gastroesophageal Reflux Disease)

Kidney Disease

Liver Disease

Anemia

Chronic Fatigue Syndrome

Fibromyalgia

Autoimmune Disease (e.g., Lupus, Multiple Sclerosis)

Depression

Anxiety

Alzheimer’s Disease

Dementia

Cancer (specify type in additional notes)

Eczema

Family History & Genetic Predispositions

Cardiovascular and Heart Disease

Stroke

High Cholesterol

Type 1 Diabetes

Type 2 Diabetes

Osteoporosis

Rheumatoid Arthritis

Osteoarthritis

Alzheimer’s Disease

Dementia

Hyperthyroidism

Kidney Disease

Liver Disease

Autoimmune Disease (e.g., Lupus, Multiple Sclerosis)

Dementia

Cancer (specify type in additional notes)

Mental Health Disorder

MTHFR Mutation

Recent Illness or Surgery

Allergies

None

Dairy

Gluten

Shellfish

Fish

Nuts (General)

Peanuts

Tree Nuts

Soy

Eggs

Wheat

Corn

Sesame

Sulfites

Artificial Additive

Medicine

Mental Clarity and Focus

Digestive Issues

None

Bloating

Constipation

Diarrhea

Gas

Acid Reflux

Other

What about your Bowel Movements ?

Daily

Every 2-3 days

Weekly

Irregular

Environmental Toxin Exposure

Low

Moderate

High

Don't know

Skin Health

Healthy

Dry

Acne-Prone

Sensitive

Aging Signs

Eczema

Hair Quality

Strong and Healthy

Thinning

Brittle

Oily

Dry

Nail Quality

Strong

Brittle

Discoloration

Smooth

Menstrual Health (for Women)

Regular Cycle

Irregular Cycle

PMS

Perimenopause

Menopause

Prostate Health (for Men)

Libido / Energy Level

Primary Goals & Secondary Goals

	Primary Goals	Secondary Goals
Weight Loss
Weight Gain
Muscle Gain
Improve Endurance
Cardiovascular Health
Lower Cholesterol
Blood Sugar Control
Bone & Joint Health
Skin Health (general)
Anti-Aging
Libido
Prostate Health
Hair and Nail Health
Cognitive Support, Memory, Focus and Concentration Support
Stress Management
Mood Enhancement
Energy Boost
Improved Sleep
Anxiety Reduction
Digestive Health
Detoxification Support
Inflammation Reduction
Immune Support
Menopause Support
Hormonal Balance
Menstrual Health
Liver Health
Kidney Health
Vision Health
Thyroid Support
Enhanced Athletic Performance
Recovery and Healing
Respiratory Health
Other (with free text option for details)

Timeline for Goals

Immediate

3 Months

6 Months

1 Year

Motivation Level

High

Medium

Low

Exercise Routine

Cardio

Strength Training

Yoga/Pilates

Walking

Mixed Exercise

Other

Physical Activity Level

Sedentary

Lightly Active (sports 1-3 days a week)

Moderatly Active (sports 3-5 days a week)

Very Active (sports 6-7 days a week)

Athlete

Electrolytes Lost Through Sweat

Low

Moderate

High

Diet Type

I do not have any restriction, I am Omnivore !

Vegan

Vegetarian

Pescatarian

Keto

Paleo

Gluten-Free

Dairy-Free

Soy-Free

Nut-Free

Low FODMAP

Halal

Kosher

Intermittent Fasting

Other

Meal Frequency

1 Meal/day

2 Meals/day

3 Meals/day

4+ Meals/day

Alcohol Consumption

None

Occasionally

Regularly

Daily

Smoking Status

Never

Occasional

Regular

Vegetable/Fruit Intake

Less than 1 serving/day

1-2 servings/day

2-3 servings/day

3+ servings/day

Processed Food & Snacks

Rarely

Sometimes

Often

Daily

Water Intake

Less than 4 glasses/day

4-6 glasses/day

6-8 glasses/day

8+ glasses/day

Medications 1

Medications 2

Medications 3

Average Sleep Duration

Less than 4 hours

4-6 hours

6-8 hours

more than 8 hours

Sleep Quality

Excellent

Good

Average

Poor

Stress Level

Inexistant

Low

Medium

High

Very High

Stress Management Techniques

Meditation

Exercise

Reading

Socializing

Music

Preferred Supplement Form

No Preference

Capsules

Tablets

Powder

Gummy

Liquid

Preferred Dosage Frequency

As Needed

Once Daily

Twice Daily

Three time Daily

Monthly Budget for Supplements

Less than 20 €

20 to 50 €

50 to 100 €

more than 100 €

more than 500 €

Review Frequency

Monthly

Quarterly

Annually

Never

Preferred Contact Method

Phone

Message

General Conditions

I read and accept the General Conditions

Informed Consent

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