APPLICATION FORM
 
* town:  
* street/house/flat:  
* postal code:  
* stationary phone:  
* mobile phone:  
* e-mail:  
  skype/msn/gg:  
*name/surname:  
  height:   cm
  weight:   kg
  age:   of years
 
  blood type  


health problems (chronic illnesses, taken cures):

     

Introduce please, usually eaten within one day, meals:
     

meal  

   mealtime  

products + home measures
  breakfast
  packed lunch
  dinner
  afternoon snack
  supper
     

Choose please closest for truth of the sentence:
     
- I am preparing meals and I am eating at home  
- I am buying ready meals to the consumption  
- I am buying and I am eating half-finished products of the type
     "giving in 5 minutes"		  
- I eat meals every day at the same time  
- I am leading the unsettled lifestyle  
     
     
Define the frequency of eating products from undermentioned groups please:  

 
FREQUENCY every day

a few times during the week

 time during the week time in the month never
bread
breakfast cereals, groats, the rice, the pasta
vegetables and fruits
the meat and canned meats
the milk and milk preserves
fishes
eggs
leguminous (pea, the bean)
fat (butter, oil, the lard)
sweets
salty snacks (chips, nutts)    
alcohol
different
different

Point out culinary techniques often applied please:
- cooking  
- strangling
- frying
- roasts
- different

Proszę wskazać zwykle spożywane napoje:
- water
- juices  
- carbonated drinks
- tea
- coffee
- different

define your physical activity:

Introduce personal expectations towards the treatment please:

I can allot to the treatment monthly