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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. __________________________________________________________________________________
HOJA DE PESO
Fecha Peso Peso
Accumulada
Peso Bajado Grasa Visceral BMI Musculo
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. _______________________________________________________________________________________

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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. _______________________________________________________________________________________