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, DiarreaPain in bonesAlergies or asthmaVaricose VeinsHeadache or MigrainsDiabitis or Insuline ResistanceMuscular PainsHigh Blood PressureHypothirodismHeart ProblemsCancerHIVliquid retentionCoffee DrinkingSmokingControlled susbstances abusePhysical activity

Do you consume any prescribed medicine?
SíNo

Which of the next actions you oftenly make?
Have a daily skin routineVisited a professionalUse sunscreen dailyEat Healthy

Which of next foods do you prefer?
Fried FoodJunk FoodGreasy FoodCanned FoodSausagesChocolateAvocadoMayonnaiseSaucesVegetablesFruits

Actual Weight (in pounds)

Height (in centimeters)

Skin problems that worry you
AcneExpression linesDark skin spotsPremature AgingDilated PoresGreasy SkinDry SkinScars

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SI (CON ROSTRO)SI (SIN ROSTRO)NO

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