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    Contact information

    Medical and Nutritional Questionnaire

    Kindly answer the following questions about your medical history, nutrition, and current state of health.

    1. Birth Sex:

    2. Age:

    3. Height:

    4. Weight:

    5. How often do you engage in moderate to vigorous physical activity?

    6. Type of exercise: (select as many as refer to you)

    7. Which diet are you following:

    Other type of diet

    8. Do you practice intermittent fasting?

    9. How often do you consume fiber-rich foods like:

    Fruits:

    Vegetables:

    Whole grains:

    10. How often do you consume proteins:

    11. Do you have any known food allergies or intolerances?

    What foods are you allergic/intolerant to?

    12. On average, how many liters (L) of water do you consume per day?

    13. How frequently do you consume alcoholic beverages?

    14. Do you smoke?

    15. Have you taken antibiotics in the past year?

    Frequency & reason

    16. Are you taking any other medication?

    List of medication

    17. On a scale of 1 to 10, with 1 being minimal and 10 being severe, how would you rate your stress level?

    18. Are you suffering from any of the following issues: (select as many as apply to you)

    Other gastrointestinal issues

    Data Consent form - Research Purposes

    I acknowledge that my Personal (Health) Data and remaining sample could contribute to further research, development, and enhancement of diagnostic techniques and potential therapeutic remedies. I consent to The BioArte's storage once pseudo anonymized, of:

    • My Personal (Health) Data and analytical results.

    • Both original and processed sample

    and that it will be kept by The BioArte for a minimum period of 10 years.

    Kindly read the full consent on this link: Data Consent and give your acceptance below to proceed with the questionnaire.

    Have you read the Data Consent?

    Do you accept the terms in the Data Consent?