Questionário smart-ageing en | FACELAB®

Have you had or are you going to have any relevant surgery?

No Yes

Do you have or have you ever had cancer?

No Yes

Have you ever had a stroke?

No Yes

Have you ever had an acute myocardial infarction (MI)?

No Yes

Have you ever had any peripheral arterial disease?

No Yes

Have you ever had any deep vein thrombosis?

No Yes

Have you ever had any retinal artery thrombosis?

No Yes

Have you ever had any retinal vein thrombosis?

No Yes

Have you ever had any pulmonary embolism?

No Yes

Do you have high blood pressure?

No Yes

Do you have any coagulation or thrombophilia disease?

No Yes

Do you have any liver disease?

No Yes

Have you ever been diagnosed with diabetes or insulin resistance?

No Yes

Do you have any autoimmune or chronic inflammatory diseases?

No Yes

Do you have or have you ever had any psychological condition (anxiety, depression, etc.)?

No Yes

Do you have any other diagnosed health conditions?

No Yes

Do you have drug or food allergies?

No Yes

Do you have food intolerances?

No Yes

In your family, there are cases of:

At what age did you start menstruation?

What is the frequency of your menstruation?

Your menstruation is:

Regular Irregular I don't have my period

Duration of menstruation (days)

Contraceptive method in use

Number of pregnancies

Type of delivery

Normal/ eutocic Cesarean section Other I didn't have any birth

Type of breastfeeding

Breast milk Formula powder milk Other None

How would you describe your usual diet?

Healthy and balanced Moderate With some indulgence Not very healthy

Do you have any restrictions or diet?

No Yes

Do you perform intermittent fasting?

No Yes

Do you often consume processed foods or refined sugars?

No Yes

Do you consume fruits, vegetables and whole foods regularly?

No Yes

Pratica exercício físico regularmente?

No Yes

Average duration (minutes)

Do you have a sedentary routine (a lot of sitting time)?

No Yes

Do you smoke?

No Yes

Do you consume alcoholic beverages?

No Yes

Do you drink coffee daily?

No Yes

Do you drink water during the day?

No Yes

Average hours of sleep per night?

What is your day-to-day stress level?

Low Moderate High

Do you have difficulty falling asleep or sleeping deeply?

No Yes

Do you perform relaxation practices?

No Yes

Do you feel satisfied with your life currently?

No Yes

Do you have a good social support network (family, friends, community)?

No Yes

What or what are the main objectives you would like to achieve with this consultation?

Are there specific areas of your life that you would like to improve?

Please use this space to add information you consider important

Attach relevant recent exams (analyses, TACs, MRIs, others)

I authorize Facelab to process and store my personal data provided in this form, exclusively for the purpose of providing health care, in accordance with the General Data Protection Regulation (GDPR) and the applicable national legislation (Law No.º 58/2019, of August 8th)

your beauty,
our care.

Smart-Aging and Longevity Medicine Pre-Consultation Questionnaire

Onde estamos?

ALBUFEIRA

Rua do Estádio, Quinta da Bela Vista, Lote 2
8200-127 Albufeira

FARO

Rua da PSP, nº 22
8000-408 Faro

your beauty, our care.

Smart-Aging and Longevity Medicine Pre-Consultation Questionnaire

ALBUFEIRA

Rua do Estádio, Quinta da Bela Vista, Lote 2 8200-127 Albufeira

FARO

Rua da PSP, nº 22 8000-408 Faro

Agende a sua consulta

your beauty,
our care.

Rua do Estádio, Quinta da Bela Vista, Lote 2
8200-127 Albufeira

Rua da PSP, nº 22
8000-408 Faro