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Any Addictions:
Do you smoke cigarettes? *
No
Yes
Do you drink alcohol? *
No
Yes
Enter Information:
Weight (in kg) *
Height (in cm) *
Age *
Less than 35
35-45
46
Frequency of light exercise / walk *
More than 3 days/ week
Once a week
No Exercise
Name *
Email *
Environmental Factors for occupation:
Does your occupation expose you to excessive heat, pollutants, chemicals? *
Yes
No
Signs of Hormonal Imbalances:
Lack of hair on face, feminine voice, etc.? *
Yes
No
Infections and Sexually Transmitted Diseases (STD):
Do you have a medical history of STD (HIV)? *
Yes
No
Psychological Factors:
Level of Personal / Official Stress *
Low
Moderate
High
Level of depression and anxiety *
Low
Moderate
High
Do you have adequate sleeps for 7-8 hours daily *
Low
Moderate
High
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