Questionnaire -English version Étape 1 de 6 16% Name Prénom Nom Email PhoneAddress Adresse postale Adresse ligne 2 Ville État / Province / Région ZIP / Code postal AfghanistanÅland IslandsAlbanieAlgérieSamoa américainesAndorreAngolaAnguillaAntarctiqueAntigua-et-BarbudaArgentineArménieArubaAustralieAutricheAzerbaïdjanBahamasBahreïnBangladeshLa BarbadeBelarusBelgiqueBelizeBéninBermudesBhoutanBolivieBonaire, Sint Eustatius and SabaBosnie-HerzégovineBotswanaBouvet IslandBrésilBritish Indian Ocean TerritoryBrunei DarrussalamBulgarieBurkina FasoBurundiCambodgeCamerounCanadaCap-VertÎles CaymanRépublique centrafricaineTchadChiliChineChristmas IslandCocos IslandsColombieComoresRépublique démocratique du CongoRépublique du CongoCook IslandsCosta RicaCôte d’IvoireCroatieCubaCuraçaoChypreRépublique tchèqueDanemarkDjiboutiDominiqueRépublique DominicaineÉquateurÉgypteSalvadorGuinée équatorialeÉrythréeEstonieEswatini (Swaziland)ÉthiopieFalkland IslandsÎles FéroéFidjiFinlandeFranceFrench GuianaPolynésie françaiseFrench Southern TerritoriesGabonGambieGéorgieAllemagneGhanaGibraltarGrèceGroenlandGrenadeGuadeloupeGuamGuatemalaGuernseyGuinéeGuinée-BissauGuyaneHaïtiHeard and McDonald IslandsHoly SeeHondurasHong KongHongrieIslandeIndeIndonésieIranIrakIrlandeIsle of ManIsraëlItalieJamaïqueJaponJerseyJordanieKazakhstanKenyaKiribatiKoweïtKirghizistanLao People's Democratic RepublicLettonieLibanLesothoLiberiaLibyeLiechtensteinLituanieLuxembourgMacauMacédoineMadagascarMalawiMalaisieMaldivesMaliMalteÎles MarshallMartiniqueMauritanieÎle MauriceMayotteMexiqueMicronésieMoldavieMonacoMongolieMonténégroMontserratMarocMozambiqueMyanmarNamibieNauruNépalPays-BasNew CaledoniaNouvelle-ZélandeNicaraguaNigerNigériaNiueNorfolk IslandCorée du NordÎles Mariannes du NordNorvègeOmanPakistanPalauÉtat palestinienPanamaPapouasie-Nouvelle-GuinéeParaguayPérouPhilippinesPitcairnPolognePortugalPorto RicoQatarRéunionRoumanieRussieRwandaSaint BarthélemySaint HelenaSaint-Christophe-et-NevisSainte-LucieSaint MartinSaint Pierre and MiquelonSaint-Vincent-et-les GrenadinesSamoaSaint-MarinSao Tomé et PrincipeArabie SaouditeSénégalSerbieSeychellesSierra LeoneSingapourSint MaartenSlovaquieSlovénieÎles SalomonSomalieAfrique du SudSouth GeorgiaCorée du SudSouth SudanEspagneSri LankaSoudanSurinameSvalbard and Jan Mayen IslandsSuèdeSuisseSyrieTaïwanTadjikistanTanzanieThaïlandeTimor-LesteTogoTokelauTongaTrinité et TobagoTunisieTurquieTurkménistanTurks and Caicos IslandsTuvaluOugandaUkraineÉmirats arabes unisRoyaume-UniÉtats-UnisUruguayUS Minor Outlying IslandsOuzbékistanVanuatuVenezuelaVietnamÎles Vierges britanniquesÎles Vierges américainesWallis and FutunaWestern SaharaYémenZambieZimbabwe Pays Date of birth ( yyyy-mm-dd)Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031What is/are your goal/s?( Health, sports performance, weight loss, ...) 1: --- 2:--- 3:--- 4---Medical conditions: Do you have any medical conditions?( diseases, operations,...)Do you take medications? If so, what are they and for what reasons?Is there any medical conditions in your family?What do you do for a living?Have you or your family recently experienced any major life changes?If so, please comment.With whom do you live (children, parents, relatives and/or friends)? Include agesHave you lived or traveled outside your country? If so, where and when? Part 1A-Indigestion, food repeats on you after you eatNo/RarelyOccacionallyOftenFrequentlyA-Excessive burping, belching and/or bloating following meal.No/RarelyOccasionallyOftenFrequentlyA-Stomach spasms and cramping during or after eatingNo/RarelyOccasionallyOftenFrequentlyA-Bad taste in your mouth.No/RarelyOccasionallyOftenFrequentlyB- Feel hungry an hour or two after eating a good-sized meal.No/RarerlyOccasionallyOftenFrequentlyB-Stomach pain, burning and/or aching over a period of 1-4 hours after eating.No/RarelyOccasionallyOftenFrequentlyB-Burning sensation in the lower part of your chest, especially when lying down or bending forward.No/RarelyOccasionalluyOftenFrequentlyB-Eating spicy and fatty ( fried) foods, chocolate, coffee, alcohol, citrus or hot peppers causes your stomach to burn or ache.No/RarelyOccasionallyOftenFrequentlyB- Feel a sense of nausea when you eat.No/RarelyOccasionallyOftenFrequentlyC-Indigestion, fullness or tension in your abdomen is delayed, occuring 2-4 hours after eating a meal.No/RarelyOccasionallyOftenFrequentlyC-Lower abdominal discomfort is relieved with the passage of gas or with bowel movement.No/RarelyOccasionallyOftenFrequentlyThe consistency or form of your stool changes within the course of the day ( e.g., from narrow to loose)First ChoiceSecond ChoiceThird ChoiceC- Stool odor is embarassingNo/RarelyOccasionallyOftenFrequentlyC-Undigested food in your stoolNo/RarelyOccasionallyOftenFrequentlyThree or more large bowel movements dailyNo/RarelyOccasionallyOftenFrequentlyC- Diarrhea ( frequent loose, watery stool)No/RarelyOccasionallyOftenFrequentlyC-Bowel movement shortly after eating ( within 1 hour)First ChoiceSecond ChoiceThird ChoiceD-Discomfort, pain or cramps in your colon ( lower abdominal area)No/RarelyOccasionallyOftenFrequentlyD-Generally constipated ( or straining during bowel movement)No/RarelyOccasionallyOftenFrequentlyD-Pass mucus in your stoolNo/RarelyOccasionallyOftenFrequentlyD-Alternate between constipation and diarrheaNo/RarelyOccasionallyOftenFrequentlyD-Rectal pain, itching or campingNo/RarelyOccasionallyOftenFrequently Part IISelect the signs and symptoms you had in the last 30 days. When massaging under your rib cage on your right side, there is pain, tenderness or soreness. Bitter fluid repeats after eating. Feel abdominal discomfort or nausea when eating rich, fatty or fried foods. General feeling of poor health. Aching muscles not due to exercice. Very strong body odor. Bruise easily Reddened skin, especially palms. Part IIISelect the signs and symptoms you had in the last 30 days. Feel cold or chilled - hands,feet or all over - for no apparent reason Muscles are weak, crramp and/or tremble Are you forgetful? Reaction time seems slowed down. In general, are your disinterested in sex because your desire is low? Feel slow-moving, sluggish Dryness, discoloration of skin and/or hair Thick , brittle nails Weight gain for no apparent reason Lingering mild fatigue after exertion or stress Do you find that you get tired and exhaust easily? Craving for salty foods Sensitive to minor changes in weather and surroundings Dizzy when rising or standing up from a kneeling position. Wounds heal slowly Feel puffy and swollen all over your body. Select the signs and symptoms you had in the last 30 days.Part IVSelect the signs and symptoms you had in the last 30 days. A sens of weakness A sudden sens of anxiety when you get hungry Wake up at night restless Poor memory, forgetfull Confused and disoriented Agitation, easily upset, nervous Blurred vision or double vision Feel clumsy and uncoordinated Frequent urination during the day and night Unusual thirst- feeling like you can't drink enough water Unusuel hunger- eating all the time Sens of drowsiness, lethardy during the day not associated with missing meals or not sleeping. Eating starchy foods, even if they are healthy and unprocessed ( like rice, corn, beans, whole wheat or oats), causes you to gain weight or prevents you from losing weight. Part VSelect the signs and symptoms you had the last 30 days. Exhaustion with minor exertion Heavy sweating ( no exertion, no hot flashes) Difficult catching breath, especially during exercise Heart pounding sensation of heart beating too quickly, too slowly or irregularly Swelling in feet, ankles and/or legs comes and goes for no apparent reaon Muscle pain at rest Cramp-like pains in your ankles, calves, legs Cold feet and/or toes appear blue Nausea comes and goes quickly ( unrelated to eating) leg discomfort or fatigue relieved by elevating legs Brief moment of hearing loss Feel worse standing: Legs get heavy and fatigued Part VI No more interests in your family, friends, work, hobbies or activities? Do you cry? Does life look entirely hopeless? Would you describe yourself as feeling miserable and sad, unhappy or blue? Do you find it hard to make the best of difficult situations& Sleep problems - Too much or too little Changes in your appetite and weight Lately you've noticed an inability to think clearly Does worrying get your down? Would you consider yourself a nervous person? Do you feel easily agitated? Do you shake and tremble? Do you tremble or feel weak when someone shout at you? Do frightening thoughts keep coming back in your mind? Do you have frequent nightmares? Do you feel pent up and ready to explode? Are you prone to noisy and emotional outbursts? Do you do things on impulse? Are you easily upset or irritated? Does it make you angry to have anyone to tell you what to do? Do you flare up in anger if you can't have what you want right away? Part VII Eyes water or tears Mucus discharge from the eyes Ears ache, itch, feel congested or sore Discharge from ears Is your nose actually congested? Nosebleeds Do you have to clear your throat? Do you suffer from severe colds? Do frequent colds keep you miserable during all winter? Chest discomfort or pain Do you have severe soaking sweats at night? Are you sleepy during the day? Do you have difficulty concentrating? Eyes, ears, nose, throat, lung symptoms seem associated with specific foods like dairy or wheat products Eyes, ears, nose, throat and lung symptoms are associated with seasonal changes Part VIII Generalized sens of water retention throughout your body Strong smell urine Rarely feel the urge to urinate Pain or burning when urinating Involuntary loss of urine when you cough, lift something or strain during an activity Part IX Localized bone pain Upper back pain Lower back pain Pain when sitting down or walking Shins hurt during or after exercise Hands, feet or throat get tight, spasm of feel numb Are you stiff in the morning when you wake up? Difficulty bending down and picking clothing or anything from the floor. Joint swelling, pain of stiffness involving one or more areas. Joint hurt when moving or when carrying weight Injure, strain or sprain easily Muscles stiff, sore, tense and/or achy Muscles cramps or spasms Headaches Difficult to recover from training Muscke twitch or tremor- eyelids, thumbs, calf, muscle Part X Head feel heavy Dizziness Need 10-12 hours of sleep to feel rested Difficult absorbing new information Tend to forget things Trouble thinking or concentrating Easily distracted Do you have a tendency to become frustrated quickly? Finishing tasks is easier said than done. Low tolerance for stress and otherwise ordinary problems. Part XI- MEN ONLY Untitled Sensation of not emptying your bladder completely Need to urinate less than 2 hours after you have finished urinating Have a weak urinary system Need to push or strain to begin urinating Dripping after urination Urgen to urinate several times a night Part XII - WOMEN ONLYMenopausal women should skip to Section E and FSection A Anxious, irratable, restless Numbness, tingling in hands and feet Easy to anger, resentful Aggressive or hostile toward family/friends Adominal bloating, feeling swollen Temporary weight gain Breast tenderness, swelling Appareance of breats lumps Diascharge from nipples Nausea and/or vomiting Diarrhea or constipation Aches and pains ( back, joints) Craving for sweet Increased appetite or binge eating Headaches Being easily overwhelmed, shaky or clumsy Heat pounding Dizziness or fainting Confused and forgetful to the point that work suffers Overwhelmed with feelings of sadness and worthlessness Difficulty sleeping of falling asleep Engaging in self-destructive behavior Section B Cramping in lower abdomen or pelvic area Lower abdominal pain is sharp and/or dull or intermittent Bloating and sebs of abdominal fullness Diarrhea or constipation Nausea and/or vomiting Low back and/or legs ache Headaches Unusual fatigue ( take naps) resulting in missed work Painful and/or swollen breasts Scanty blood flow Section C Painful or difficult intercourse Low abdominal , back and vaginal pain Pelvic pressure or pain while sitting down or standing up, relieved by lying down Vaginal bleeding other than during your period Painful bowel movements Difficult (straining) urination Abnormal vaginal discharge Vaginal itching or burning with or without intercourse Pain during periods is getting progressively worse Profuse or prolonged menstrual bleeding Unable to get pregnant Section D Absence of periods for six months or longer Periods occur irregularly (e.g., 3 to 6 times a year) Profuse heavy bleeding Menstrual blood contains clots and tissue Bleeding between periods can occur anytime Periods occur greater than every 35 days Intense upper stomach pain, lasting several jours at the time you ovulate ( approx. day 14 of your cycle) Bleeding occur at ovulation ( approx. 14 days of your cycle) Monthly abdominal pain without bleeding Acne and/or oily skin Overwhelming urges for sexual intercourse Aggressive feelings Voice si becoming deeper Breats seem to be getting smaller Section E Vaginal discharge Vaginal secretions are watery and thin Vaginal dryness Sexual intercourse is uncomfortable Interest in having sex is low Engorged breats Breats tenderness, soreness Difficulty with orgasm Vaginal bleeding after sexual intercourse Section F Sense of well-being fluctuates throughout the day for no apparent reason Sudden hot flashes Spontaneous sweating Chills Cold hands and feet Heat beats rapidly of feels like it's fluttering Numbness, tingling or prickling sensations Dizziness Mental fogginess, forgetful or distracted Inability to concentrate Depression, anxiety, nervousness and/or irritability Difficulty sleeping Skin, hair, vagina and/or eyes feel dry Stopped menstruating around six months ago, yet still experience some vaginal bleeding Thanks Δ