FD – Preliminary Questionnaire – Food Dependence Step 1 of 4 – Personal information 0% Personal InformationName(Required) First Name Last Name Date of birth(Required) MM slash DD slash YYYY E-mail(Required) Personal health historyHave you ever suffered or suffer from physical illnesses?(Required) Cardiovascular disease (angina, myocardial infarction, stroke, heart attack, bypass surgery, intermittent claudication…) Hypertension (high blood pressure) Diabetes, prediabetes, insulin resistance, gestational diabetes Polycystic ovary syndrome Lung diseases (asthma, emphysema, COPD…) Neurological diseases (neuropathies, multiple sclerosis, migraines, Parkinson’s disease…) Autoimmune or inflammatory diseases (rheumatoid arthritis, type 1 diabetes, systemic lupus erythematosus, scleroderma…) Dermatological diseases (eczema, psoriasis, lichen planus, lichen sclerosus…) Cancer (please specify the type of cancer, year of diagnosis, stage, treatment(s) received and if you are in remission) Gastrointestinal diseases or problems (gastroesophageal reflux, Crohn’s disease, ulcerative colitis, irritable bowel syndrome, SIBO, etc.) Chronic pain (osteoarthritis, lower back pain, neuralgia, shingles, etc.) Memory disorders (Alzheimer’s disease, dementia…) Musculoskeletal diseases (tendinitis, osteoarthritis, osteoporosis…) Gynecological diseases (hormonal imbalance, abnormal bleeding, endometriosis) Sleep apnea and hypopnea syndrome. If so, do you wear a CPAP to sleep? Additional Specifications *Have you ever suffered or are suffering from mental health issues?(Required)Describe the difficulty(s), the treatment(s) attempted (drugs, therapies…) and the context if applicable with the year. This includes anxiety, depression, burn-out, adjustment disorder, bipolar affective illness, schizophrenia, toxic or drug psychosis, eating disorder, personality disorder, addiction and/or abuse of alcohol or drugs…(Required)Have you ever been operated on? Specify the surgery and the year(Required)Do you take medication? Specify(Required)Do you take supplements or vitamins? Specify(Required) Family antecedentsWhat is or was your father's state of health?(Required)What is or was your mother's state of health?(Required)What is or was the state of health of your siblings (brothers and sisters)?(Required)What is the state of your children's health?(Required)Do you have other family health histories in the more distant family (uncles, aunts, grandparents) that seem relevant to you (several cancers, young heart problems, autoimmune diseases, mental health problems, addictions…)(Required) LifestylesDo you smoke or have you ever smoked? If so, how many cigarettes per day for how many years?(Required)Do you consume alcohol: IF yes how many drinks per week on average?(Required)Do you consume cannabis? If yes, how often?(Required)Do you use other drugs? If so, which ones and how often?(Required)Do you exercise: describe what types of exercise and the frequency?(Required)Tell us about your sleep: routines, number of hours, quality, treatments attempted?(Required)Tell us about your current diet (omnivorous, carnivorous, vegetarian, vegan, low in carbohydrates, ketogenic, carnivorous, anti-inflammatory diet…)(Required)How do you manage your stress (meditation habits, exercise, breathing, moments in nature, crafts, application of techniques learned in therapy…)(Required)What is your current living situation: do you live alone. e or with whom, are you in a relationship?(Required)Do you or have you consulted health care professionals or have you taken steps in the past or currently to take care of your health, attempt to treat your problems or symptoms, prevent diseases or optimize your health?(Required)CAPTCHA
