Have you ever suffered, or actually suffers from any of the next listed diseases, problems or habits, related to nutrition Tummy Problems (reflux, heartburn, stomach ulcer) Constipation, Diarrea Pain in bones Alergies or asthma Varicose Veins Headache or Migrains Diabitis or Insuline Resistance Muscular Pains High Blood Pressure Hypothirodism Heart Problems Cancer HIV liquid retention Coffee Drinking Smoking Controlled susbstances abuse Physical activity
Do you consume any prescribed medicine? Sí No
Which of the next actions you oftenly make? Have a daily skin routine Visited a professional Use sunscreen daily Eat Healthy
Which of next foods do you prefer? Fried Food Junk Food Greasy Food Canned Food Sausages Chocolate Avocado Mayonnaise Sauces Vegetables Fruits
Actual Weight (in pounds)
Height (in centimeters)
Skin problems that worry you Acne Expression lines Dark skin spots Premature Aging Dilated Pores Greasy Skin Dry Skin Scars
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SI (CON ROSTRO) SI (SIN ROSTRO) NO
Have you ever suffered, or actually suffers from any of the next listed diseases, problems or habits, related to nutrition Tummy Problems (reflux, heartburn, stomach ulcer) Constipation, Diarrea Pain in bones Alergies or asthma Varicose Veins Headache or Migrains Diabitis or Insuline Resistance Muscular Pains High Blood Pressure Hypothirodism Heart Problems Cancer HIV liquid retention Coffee Drinking Smoking Controlled susbstances abuse Physical activity
Do you consume any prescribed medicine? Sí No
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Pants Size XS S M L XL XXL
Reason(s) for consultation Weight Loss Habits change, eating plan Increase Energy Levels Green Juice Recipes Celulitis Healty food recipes
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Back Full Body Picture, with extended arms (no face)
Left Full Body Picture, with extended arms (no face)
Right Full Body Picture, with extended arms (no face)
SI (CON ROSTRO) SI (SIN ROSTRO) NO
