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Intake questionnaire - 40 questions

1. Health & complaints

3. Did the complaints develop gradually or suddenly?
Gradual
Suddenly
Not sure
4 a. Have you tried to get rid of these complaints before?
Yes
No
6. How much influence do your complaints have on your daily life (work, relationships, energy, mood)?
No influence
Mild influence
Moderate influence
Great influence
Very big influence

2. Sleep & recovery

8. How would you describe your sleep quality?
Very good
Good
Changing
Moderate
Bad
9. How many hours of sleep do you get on average per night?
Less than 5 hours
5–6 hours
6–7 hours
7–8 hours
More than 8 hours
10. Do you wake up refreshed in the morning?
Yes, usually
Sometimes
Seldom
Never
11. Do you have trouble falling asleep, staying asleep, or waking up too early?
Difficulty falling asleep
Difficulty sleeping through the night
Woke up too early
None of the above

3. Stress, emotions & mental strain

13. How often do you experience stress?
Seldom
Every now and then
Regularly
Often
Almost daily
16. Do you regularly experience feelings of tension, restlessness, or overstimulation?
Yes, often
Sometimes
Seldom
Never
17. How would you describe your general mood over the past few weeks?
Positive
Neutral
Changing
Negative

4. Exercise & physical strain

18. How often do you exercise per week? (at least 30 minutes each time)
Less than 1 time
1–2 times
3–4 times
5 times or more
19. How much time do you spend sitting each day?
Less than 4 hours
4–6 hours
6–8 hours
More than 8 hours
20. Do you suffer from stiff muscles, joint pain or physical limitations?
Stiff muscles
Joint complaints
Back pain
Neck/shoulder complaints
Physical limitations
None of the above
21. How would you describe your energy level during the day?
High
Reasonable
Changing
Low

5. Nutrition & eating habits

23. Do you eat regularly (fixed meals) or irregularly?
Regularly
Irregular
Changing
24. Do you suffer from binge eating, sweet cravings, or emotional eating?
Binge eating
Craving for sweets
Emotional eating
None of the above
25. How much water do you drink on average per day?
Less than 1 liter
1–1.5 liters
1.5–2 liters
More than 2 liters
26. Do you use caffeine, alcohol, tobacco, or other stimulants?
Caffeine
Alcohol
Tobacco
Energy drink
Other
None of the above

6. Lifestyle, environment & routines

30. How supportive is your environment in improving your lifestyle?
Very supportive
Supporting
Neutral
Not supportive
Counterproductive

7. Digestion & gut health

31. How often do you have a bowel movement?
Less than 3 times a week
3–5 times a week
Daily
Several times a day
32. How would you describe the consistency of your stool?
Hard / dry
Normal
Soft
Aqueous
33. Do you regularly suffer from bloating?
Yes, often
Sometimes
Seldom
Never
34. Are you experiencing diarrhea or constipation?
Diarrhea
Blockage
Alternating diarrhea and constipation
None of the above

8. Goals & motivation

9. Lichaamswaarden

  1. Meet je buikomvang met het meetlint dat je van ons hebt ontvangen. Plaats het lint op de hoogte net onder je navel en trek het licht aan - niet te strak, maar goed aansluitend.

    Meet je bloeddruk bij voorkeur in de ochtend, op een nuchtere maag en in een rustige houding. Zo krijg je de meest betrouwbare waarden.

9. Optional photo upload

41. Would you like to upload a photo that shows your current body condition?
Yes, I would like to upload a photo
No, I'd rather not
Maybe later
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