Smoker Ex-smoker since years

How many cigarettes, cigars, pipes… do/did you smoke per day? 1-5 6-10 11-20 >20 Physical activity (at least 30 min) Daily 1x/week 2x/week 3-6/ week Endurance sports (e.g. jogging, biking, hiking, swimming…) Power training (e.g. weight lifting…) Mind-body sports (e.g. Pilates, Yoga) Frequent prolonged immobility

Stress

Age Gender Female Male Height cm Weight Kg Blood group

0 A B AB

Ethnic origin Caucasian Asian African

Allergies

Digestive problems

Diabetes Type 1 Type 2 Hypertension

Cardiac insufficiency

Hyperlipidaemia

Hiperuricemia

Alzheimer’s disease

Cáncer

Liver

Bladder Lung Kidney

Colon Leukaemia Stomach Breast Skin

Obesity

Thrombosis

Oedema

Kidney disease

Liver disease

Thyroid disease Hypofunction

Hyperfunction

Cardiovascular disease

Myocardial infarctionInflammatory disease Crohn’s disease Ulcerative colitis

Statins Other lipid-lowering Antihypertensives Diuretics Antiplatelet drugsAnticoagulants

Coumarin derivatives

Heparin

Analgesics (painkillers) Never Sometimes Regulary Paracetamol Ibuprofen Glucocorticoids Cortisone Antidepressants

Barbiturates

Anticonvulsants Valproic acid Carboxamides Benzodiazepine Hormone replacement therapy Estrogens Gestagen Testosterone < 5 years > 5 years Oral contraception Discontinued Long term

Dietary supplements Vitam.B Complex B3 B6 B9 B12

Food intolerance(s) Gluten

Fructose

Lactose

Food allergy Tree nuts Peanuts

Fish Shellfish Eggs Milk Soy

Vegetarian Vegan

Red wine

1-2 glasses/day > 2 glasses/day

Alcohol diferente/adicional

Coffee

1-3 cups/day > 3 cups/day

Tea (white, black or green tea)

1-2 cups/day > 2 cups/day

Energy drinks (rich in caffeine, guarana, taurine. p.e. Red Bull)

Soft drinks Containing phosphoric acid e.g. cola, sodas Daily fluid intake

≤1L 2L ≥3L

REGULAR CONSUMPTION: Fruits and vegetables

Carbs with high glycemic index (GI)

White bread/pasta/rice, sugar

Carbs with low glycemic index (GI) Legumes, grain, fruits, vegetablesDietary fibres Legumes, grain products, fruits, vegetables Dairy products Milk, yoghurt, curd cheese

Calcium-rich products

Dairy products, sardines, green vegetables

Soy products Tofu, tempeh, soy milk, soy beans

Red meat Beef, pork, lamb, duck, game, horse

1-2 x week 3-4 x week +5 x week White meat Chicken, turkey, rabbit, veal. Fish

Blue Fish (salmon, mackerel, herring)Sea food

Clams, mussels, cuttlefish, shrimp, lobster

Surname

Name

Birthdate

Surname

Name

Vitam.C Vitam.D Vitam.E Omega 3 Calcium Magnesium Selenium Zinc

Omega-3 fatty acids

Salmon, herring, linseed oil, Chia seeds

Saturated animal fatsButter, cheese, cream, bacon

Vegetable oils Olive oil, linseed oil, rapeseed oil. Salt rich products Crisps, pickles, anchovies, cured meat

Raw sugar honey, sweets Check only if consumed in notable quantities

Deep-fried food

French fries/chips, potato chips fried chicken

Grilled/smoked food Barbecued meat or fish

“Light” products

Fat or sugar reduced food

Convenience/fast food

first and second degree relativesDiabetes

Hypertension

Hyperlipidaemia

Alzheimer’s disease

Parkinson’s disease

Thyroid disease

Cardiovascular disease

myocardial infarction

Thrombosis

Obesity

Osteoporosis

Cancer

TomatoesGreen leafy vegetables (e.g. spinach, chard, lettuce, field salad,)Cruciferae (broccoli, sprouts, cauliflowe) Apiaceae (carrots, fennel, celery, parsnips)

drugs

Yes No

1-2 glasses/day > 2 glasses/day

Liver

Bladder Lung Kidney Colon Leukaemia Stomach Breast Skin

SaludADN ®

by eugenomicHEALTH QUESTIONNAIRE - DETOXgenesPATIENT INFORMATION

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PERSONAL PROFILE

LIFESTYLE FACTS

CURRENT MEDICATION

ABOUT YOUR NUTRITION

CURRENT MEDICATION ABOUT YOUR NUTRITION YOUR MEDICAL HISTORY

YOUR FAMILY MEDICAL HISTORY

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ADN&Salud by EUGENOMIC®. Tel. 902 107 435. e-mail: info@adnsalud.com. web: www.adnsalud.com

Skin disease Which?

Other disease(s)/disorder(s)

Other disease(s)/disorder(s)

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Never Sometimes Regulary

Never Sometimes Regulary

Yes No

Yes No

Yes No

Yes No

Yes No Yes No Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

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Yes No

Yes No

Yes No

Yes No

Yes No

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Yes No

Yes No Yes No

Yes No Yes No Yes No Yes No Yes No

Yes No Yes No Yes No Yes No Yes No Yes No

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Yes No

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Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Never Sometimes Regulary

(Sedentary work/lifestyle, long flights/car rides)

Alopecia (hair loss) Yes No

Mood disorders Yes NoMood changes, depression

Lack of energy, fatigue Yes No

Never Sometimes RegularyAgitation, hyperactivity

Never Sometimes RegularyAnxiety Never Sometimes Regulary

Infections in the mouth Never Sometimes Regulary

Absence of appetite Never Sometimes Regulary

Dizziness Never Sometimes Regulary

Headaches Never Sometimes Regulary

Attention deficit / memory troubles Never Sometimes Regulary

Agitated sleep, insomnia Never Sometimes Regulary

Joint and muscle pain Never Sometimes Regulary

Prickling in hands/feed Never Sometimes Regulary

Circulatory disturbances Never Sometimes Regulary

YOUR MEDICAL HISTORY

Anaemia Yes No

Susceptible for infects Yes NoArthritis Yes No

ENVIRONMENTAL EXPOSURE

Dental amalgamHeavy metalscadmium, lead, mercuryPaints, solvents, glues Epoxy resinsPesticides, insecticides,

PCBs Polychlorinatedbiphenyls, plasticizers, PVC coatings Car exhaust fumes

Hair dyes

working/living in the city

herbicides

Yes No Yes No Yes No Yes No Yes No Yes No

Yes No

Yes No