Iaso tea encuesta (1)
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The document appears to be a health survey containing sections for personal information, current health problems, products, and referrals. It collects the name, address, phone number, date of birth, gender, age, height of the participant. It lists several common health problems to check off including diabetes, high blood pressure, cholesterol, cancer, anxiety, headaches, and others. Sections also include products and 10 referral contacts.
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Iaso tea encuesta (1)
- 1. ENCUESTA DE SALUD Nombre: _____________________________________________ Fecha: ____________________________ Dirrecon: _________________________________________________________________________________ Telephono: ____________________ Fec ha de Nac: ____________________________________________ Sexo: ________________ Edad:_____________ Estatura: ___________________ __________________________________________________________________________________________ Preblemas de Salud: __Diabetes __ Presión Alta __Acides __Colesterol __Cancer __Estreñimiento __Gastritis __Asma __Ansidad __ Dolor de Extremidades __ Varicies __ Fatiga __ Problemas Mentruales __ Insomnio __ Depression __HIV __ Nervioso __Dolor de Cabeza __ Colitis __ Diverticulitis __ Alergias __Estres __ Falta de Energia __Problema de los Riñones __Problemas del Higado __Acné __ Caida De Cabello __ Psorisis __________________________________________________________________________________________ Productos: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Refeidos: Tele/email 1. ____________________________________________________________________________________ 2. ____________________________________________________________________________________ 3. ____________________________________________________________________________________ 4. ____________________________________________________________________________________ 5. ____________________________________________________________________________________ 6. ___________________________________________________________________________________ 7. ___________________________________________________________________________________ 8. __________________________________________________________________________________ 9. ___________________________________________________________________________________ 10. __________________________________________________________________________________
- 2. HOJA DE PESO Fecha Peso Peso Accumulada Peso Bajado Grasa Visceral BMI Musculo
- 3. HEALTH SURVEY Name ___________________________________________________Date: ____________________________ Address: _________________________________________________________________________________ Telephone: _____________________________ DOB : ____________________________________________ Gender: ________________ Age: _____________ Height: ___________________ __________________________________________________________________________________________ Health Problemas: __Diabetes __ High pressure __Acides Reflux __Cholesterol __Cancer __Constipation __Gastritis __Asthma __Aniexty __ Varical Viens __ Fatigue __Menstrual problems __ Insomnia __ Depression __HIV __Nervous _Headache __ Colitis __ Diverticulitis __ Allergies __Stress __ Lack of energy __Problema Kidney ___Liver __Problemas __Acne _________________________________________________________________________________________ Products: __________________________________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Referals: Tele / email 1. ________________________________________________________________________________________ 2. ________________________________________________________________________________________ 3. ________________________________________________________________________________________ 4. ________________________________________________________________________________________ 5. ________________________________________________________________________________________ 6. ________________________________________________________________________________________ 7. ________________________________________________________________________________________ 8. _______________________________________________________________________________________ 9.________________________________________________________________________________________ 10. _______________________________________________________________________________________