Entry form

Personal information

Name and surname

Permanent residence

Date of birth

Phone number

E-mail

Personal identification number

Close contact person(s) and name

What issue

Food

Food allergies

Gluten intolerance

YES NO

Lactose intolerance

YES NO

Dietary restrictions

List the foods you don't eat

Medical restrictrions

Physical health limitations

Activities that I cannot do due to my health limitation

Allergy

Medication

Regularly taken medications

Irregularly taken medications

When are they used? (time, relationship to food, etc.)

How did you hear about us?

Internet:

Advertisement or commercial message? From an article about NEO or an interview with NEO therapists Social networks

Recommendation:

From a former client From a person who knows NEO by ear From another therapist, professional, or doctor

Do you follow our social networks?

Instagram Facebook LinkedIn

Thank you for your time and input

I agree with the provision of personal data.