Work with me to longevity!

In Functional medicine, it’s often not a one-size-fits all sort of solution but more of a customized solution tailored to individual needs. That’s why its really important give us an extended explanation of the symptoms you have, some things might be related without you knowing that it was ‘not usual’.

On this page, there is a short questionnaire that sends the results to me. I will carefully analyze the information and offer you preliminary advice, free of charge.

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Name *

First

Last

Email *

Age

Where are you located?

Height

Weight

What symptoms do you regularly experience (multiple answers possible)

• Persistent bloated feeling, especially after specific foods
• Constipation (hard stool, regularly skipping a day)
• Diarrhea (very soft stool, regularly rushing to the toilet
• Cravings, either sugar or salty
• Fatigue upon waking up
• Not being able to sleep through the night, wake up around 3am
• Feeling that eating a piece of cake immediately affects the body
• Afternoon dip, a siesta wouldn’t hurt
• Regularly a warm red face after drinking alcohol or eating specific foods
• Eczema that fluctuates in severity
• Palpitations
• Unable to lose weight
• Irregular menstruation
• Extreme moodswings
• Takes longer than 30 minutes to fall asleep
• Water retention, especially in face and around abdominals
• Headaches
• No energy
• Negative thoughts
• Brittle nails
• Hair loss, thinning
• Skin issues

Are there specific times that symptoms get worse?

Let's get to know you a little better now..What sort of job do you have?

• I have a sedentary job
• I am relatively active
• I am on my feet all day
• Other..

What's your profession?

What sports do you do?

• I don’t do any sports
• I walk regularly
• I run short distances
• I run long distances
• Other cardio (biking, swimming, etc…)
• I do strength training
• I do yoga/pilatus
• Other..

The sports I do regularly:

Do you drink Alcohol?NoYes, once every month or soYes, every week 1-2 glassesYes, every week 3-6 glassesYes, every week more than 6 glasses

Do you smoke?YesNoOccasionally

What diet do you follow?No dietVeganVegetarionFlexitarianPescetarianFodmapCarnivoreLow carbKetoLow-histamineMediterraneanOther..

I'm following this diet:

Are you allergic to somethng? If so, explain..

Have you had professional help yet?Yes, the doctorYes, a specialistNo

Have you tried solving your issues before? If so, how? and what did you find out?

What personality treats would you say match best with you (choose as many as you want)

• I love working out and being active
• I love going for long walks
• I love any workout that makes my heartbeat go up
• I am a strong person (physically)
• I like to set goals and work toward something
• I love trying new things
• A plan without a goal doesn’t work for me
• I have days that I relax and watch movies all day
• I go out for dinner at least 2 times a week(sometimes more, take away counts)
• I love cooking and trying new recipes

Describe what a normal day of eating looks like for you:

What would your life look like and what would be different if we solve your symptoms?

How did you hear about me?InstagramA friendGoogleOther

Is there anything else I should know about you?

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