questionnaire - Viva Glow Drip in Limassol

Name

Birthday

E-Mail

Phone

Profession

Reason

Goals

Complaints/Symptoms

Causes, Connections

Previous Treatments

Medical conditions

Allergies

Have you ever had abnormal liver or kidney values?

Yes No

Have you ever had contrast media during MRI or CT scan?

Yes No

Do you drink 2–3 liters of water daily?

Yes No

Do you consume coffee or other caffeinated drinks?

Yes No

Amount Coffee

Do you drink alcohol?

Yes No

Amount Alcohol

Do you smoke?

Yes No

Amount Smoking

Do you regularly drink sweetened beverages?

Yes No

Do you mainly eat organic food (approx. 80%)?

Yes No

Do you eat vegetables and fruits daily?

Yes No

Do you consume cow’s milk products?

Yes No

Do you eat foods containing gluten?

Yes No

Do you use ready-made or convenience meals?

Yes No

Do you follow a vegan or vegetarian diet?

Yes No

Do you tolerate your food well (no bloating, heartburn, etc.)?

Yes No

How often do you have bowel movements?

1-2 daily Irregular Constipation Diarrhea

Do you experience abdominal cramps or discomfort?

Yes No

Have you taken antibiotics or corticosteroids in the past?

Yes No

Sleep Hours

Do you fall asleep easily and wake up refreshed?

Yes No

Do you have long wake phases during the night?

Yes No

Do you sweat excessively at night?

Yes No

Do you wake up at night with heart palpitations?

Yes No

Do you experience an afternoon slump (around 3 p.m.)?

Yes No

Do you exercise regularly or weekly?

Yes No

Do you walk daily (6,000–10,000 steps)?

Yes No

Are you outside in daylight for about 1 hour per day?

Yes No

Do you take daily rest breaks or allow yourself regular relaxation?

Yes No

Current stress level:

Low Moderate High

Do you rarely get sick (fewer than 2 infections per year)?

Yes No

you suffer from chronic infections?

Yes No

Do you have skin issues (e.g., acne, eczema, psoriasis)?

Yes No

For women only: Is your menstrual cycle regular (28–32 days)?

Yes No

For women only: Do you experience menstrual or menopausal complaints?

Yes No

For women only: Do you use hormonal contraception (pill, IUD, etc.)?

Yes No

Hormonal Contraception

Do you have amalgam fillings?

Yes No I don't know

Did your mother have amalgam fillings?

Yes No I don't know

Do you have any metal implants, screws, or pacemakers?

Yes No

Do you primarily use organic cosmetics and cleaning products?

Yes No

Do you use your own Wi-Fi daily?

Yes No

Is your Wi-Fi on at night?

Yes No

Do you keep electronic devices near your bed?

Yes No

Have you experienced depression, anxiety, or burnout?

Yes No

Do you have problems with concentration or memory?

Yes No

Are you sensitive to environmental stimuli (light, sound, smells, etc.)?

Yes No

Mood, Balance

Medications

Supplements

Do you regularly take binders, prebiotics, or probiotics?

Yes No

Have you taken antibiotics or corticosteroids recently?

Yes No

Consent

I confirm that all information provided is complete and correct to the best of my knowledge. I consent to the storage of my data for treatment purposes and to be contacted for appointment-related communication.

Viva Glow Drip
(by Homme Avenue)
Arch. Makarios III Avenue 242-Shop 4, Limassol 3105
Phone. +35725310182

Viva Glow Drip – Wellness Lifestyle Intake Form

Welcome to Viva Glow Drip! This form helps us tailor your wellness infusion and lifestyle program. Please answer as accurately as possible to ensure safe and effective treatment.