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Anamnese
Step
1
of
7
14%
Personal Data
Name
(Required)
First
Last
Email
(Required)
Social MÃdia (Instagram | Facebook):
(Required)
Phone
(Required)
Address
(Required)
Street Address
Complement
City
State / Province / Region
Gender
(Required)
Female
Male
Others
Profession
(Required)
Worked Hours
(Required)
Weekly
Date of birth
(Required)
MM slash DD slash YYYY
Notes (optional)
Goal
What's your goal?
(Required)
Weight Gain
Weight Loss
Gain of muscle mass
Reduction of body fat
Nutritional Education
Health
Performance
Competition
Aesthetics
Others
Have you had an evaluation before by a trainer?
(Required)
Yes
No
For what purpose?
(Required)
What was the result?
(Required)
MORPHOFUNCTIONAL ASSESSMENT
Weight
(Required)
Height
(Required)
Last Body Fat
(Required)
Current Body Fat
(Required)
Blood Pressure
(Required)
Blood type
(Required)
O negative
O positive
A negative
A positive
B negative
B positive
AB negative
AB positive
Diastole
Systole
IN THE LAST 3 MONTHS HAVE YOU EXPERIENCED WEIGHT LOSS OR MAGNETIC MASS INCREASE PROCESS?
Weight Loss
(Required)
Yes
Not
Previous Weight
(Required)
Results
(Required)
Lean Mass Gain
(Required)
Yes
Not
Previous Weight
(Required)
Results
(Required)
Phase that started weight loss or muscle mass increase
(Required)
Childhood
Adolescence
Adult
SOCIAL HISTORY
Sleep quality
(Required)
Poor
Regular
Good
Great
Wake up what time ?
(Required)
Sleep at what time?
(Required)
Wake up at night?
(Required)
Yes
No
How many times ?
(Required)
Please enter a number greater than or equal to
1
.
Wake up tired?
(Required)
Yes
No
Because?
(Required)
Smoker?
(Required)
Yes
No
Amount/Day
(Required)
Please enter a number greater than or equal to
1
.
Ex-Smoker?
(Required)
Yes
No
Have you smoked for how long?
(Required)
How long did it stop?
(Required)
Use Alcohol?
(Required)
Yes
No
Amount/Day
(Required)
Please enter a number greater than or equal to
1
.
Drugs?
(Required)
Yes
No
Which are?
(Required)
Anabolic?
(Required)
Yes
No
Which are?
(Required)
Medicines?
(Required)
Yes
No
Which are?
(Required)
Hormone modulation?
(Required)
Yes
No
Which are?
(Required)
HISTORY OF PERSONAL PREGRESSES
Drug Name
Farmacology
Drug interaction
Medical / Contact
Medications
Check everything that applies.
Diabetes - Type 1
Diabetes - Type 2
Arterial hypertension
AVC
Pulmonary Diseases
Heart diseases
Kidney diseases
Hepatic diseases
Neoplasm
High Cholesterol
Low Cholesterol
High Glycemia
Low blood sugar
Hypothyroidism
Hyperthyroidism
Increased Triglycerides
Gastritis
Ulcer
Bone trauma
Obesity - Type Android
Obesity - Type Gynoid
Surgeries?
(Required)
Yes
No
Which are?
(Required)
Add
Remove
