Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name of Operator *FirstLastEmail *Date / TimeDateTimeAthlete's codeThe athlete’s ID is uniqueYour Sport *Boxing with mouthgardBoxing without mouthgardBody BuildingControlAgonist *YESYESNOSince how many years? (numerical value) *Typical duration/training session (hours, numerical value) *Number of Training sessions/week (numerical value) *Club (Spell out)Name of Medical DoctorOther sports? *Blood test available *YESYESNOTube Codethe code That it’s on your tube Ex: N1234Timepoint of collectionBaselinePre-trainingPost-trainingTime of the day (h) *Indicate the time of the day in a 24 hours cycleDate of colection *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your gender *MaleFemaleNot disclosedDate of birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Height * in cmWeight *in KgMenses Status *FertileFertileMenopause/AndropauseIf fertile, day of the cycle *AP1_Where you ever hospitalized?YESYESNOAP1_If YES please give a reasonAP2_Did you ever undergo surgery?YESYESNOAP2_If YES, which kind of surgery?AP3_Type of trauma enduredIndicate the type of trauma only if occuredAP4_Allergies to DrugsYESYESNOAP5_Allergies to FoodYESYESNOAP6_Other AllergiesYESYESNOAP7_Respiratory IllnessesYESYESNOIncluding infectionsAP8_Cardiovascular defectsYESYESNOAP9_Digestive-tract illnessesYESYESNOAP10_Urinary tract illnessesYESYESNOIncluding infectionsAP11_Neuropsychiatric conditionsYESYESNOAP12_Metabolic syndromeYESYESNOAP13_Autoimmune diseasesYESYESNOAD1_Brushing Frequency/day11234AD2_How many times do you go to the dentist/yearly0123AD3_When was your last visit at the dentist?Aproximate dateAD4_Did you loose any teeth? or have any teeth extracted?YESYESNOAD5_if YES, what was the reason?AD6_Do you have bleeding gums?YESYESNOAD7_Did you ever undergo ortodontal treatment?YESYESNOAD8_if YES, of which type?AD9_Do you suffer from gums' ulcers?YESYESNOAD10_Do you suffer from recurrent herpetic infections?YESYESNOAD11_Do you suffer from oral candidosis?YESYESNOAD12_Do you suffer from swollen or inflamed gums?YESYESNOAD13_Did you ever experience salivary glands problems?YESYESNOAD14_Did you ever suffer from emangiomas of oral cavities?YESYESNOAD15_Did you ever experiences maxillary or mandibolary abscesses?YESYESNOAD16_Are you using fluoride?YESYESNOAT1_Did you ever endure dental trauma?YESYESNOAT1_if YES, which type?AT2_Do you practice contact sport?YESYESNOAT3_Do you know about the existence of mouthgards?YESYESNOAT4_Did anyone suggested you the use of mouthgards?YESYESNOAT5_if YES, who suggested it?AT6_if YES, which type?AT7_Are you wearing mouthgards during sports?YESYESNOAT8_Of which type?PersonalizedPersonalizedCustomizedBoil& BitePrecastAT9_Did you cease to wear mouthgards?YESYESNOAT10_if YES, why?AA1_How many meals do you have a day?223456AA2_Do you eat during training?YESYESNOAA3_When do you eat ?BeforeBeforeAfterBefore and AfterWith reference to trainingAA4_Do you consume energy drinks?BeforeBeforeDuringAfterBefore and AfterBefore and DuringDuring and AfterWith reference to trainingAA4_if YES, which type?AA5_Do you consume fruit or fruit juices?BeforeBeforeDuringAfterBefore and AfterBefore and DuringDuring and AfterWith reference to trainingAA6_Do you eat snacks (salty or sweet)?YESYESNOAA6_When do you consume sweet or salty snacks?BeforeBeforeDuringAfterBefore and AfterBefore and DuringDuring and AfterWith reference to trainingAA7_Do you chocolate and/or candies?YESYESNOAA7_When do you consume chocolate and/or candies?BeforeBeforeDuringAfterBefore and AfterBefore and DuringDuring and AfterWith reference to trainingAA8_How is your typical lunch meal?Pasta/RiceMeat/Fish/CheeseVegetablesDessertClick on one or more boxesAA8_How is your typical dinner meal?Pasta/RiceMeat/Fish/CheeseVegetablesDessertClick on one or more boxesAA9_Are you followed by a dietician?YESYESNOAA9_if YES, indicate the name.IO1_TongueIO2_CheeksIO3_PalateIO4_LipsIO5_Buccal FloorIO6_FrenulesIO7_Dental AnomaliesIO8_Dental Erosions and their localizationIO9_Type of Tissue interested by Dental ErosionsEnamelDentineEnamel& DentineIO10_Type DischromiaWhiteBrownStripedDiffusedIO11_Where are they localized?Number of Tooth/Teeth interestedIO12_Necrotic teeth or degraded pulpNumber of Tooth/Teeth interestedIO13_Abscess/FistulaNumber of Tooth/Teeth interestedIO14_AbrasionsNumber of Tooth/Teeth interestedIO15_Gum RecessionsNumber of Tooth/Teeth interestedIO16_Plaque Index01IO17_Gingival Index01IO18_Bleeding Index01IO19_DMFT_Number of Teeth with Cavities012345678910>10IO19_DMFT_Number of Missing Teeth012345678910>10IO19_DMFT_Number of Filled Teeth012345678910>10IO19_Number of teethIO20_Class of AngleI classII classIII classIO21_OverbiteYESNOIO22_OverjetYESNOIO23_ParafunctionsYESNOIO24_ATMYESNOIO25_ApertureNormalReducedSB1_Prebiotic Nitrates_PrelowmediumhighSB2_Prebiotic Nitrates_PostlowmediumhighSB3_Salivary Nitrates_PrelowmediumhighSB4_Salivary Nitrates_PostlowmediumhighSB5_Salivary Uric Acid_Pre1.52.55710SB6_Salivary Uric Acid_Post1.52.55710SB7_Salivary pH_BaselineInsert number corresponding to pHSB8_Salivary pH_PreInsert number corresponding to pHSB9_Salivary pH_PostInsert number corresponding to pHQV1_Hours of sleep per night:<5 hours<5 hours5-7 hours7-9 hours>9 hoursthe average number of hours of sleep per nighQV2_Hours of sleep per night: (copy)<5 hours<5 hours5-7 hours7-9 hours>9 hoursthe average number of hours of sleep per nighQQV3_How is the quality of your sleep:Very goodVery goodGoodNormalBadVery badthe average quality of sleepQV4_Hours of sport per week:nonenone<3 hours3-6 hours>6 hoursQQV5_How often do you feel Calm/PeacefulNeverNeverOccasionallyAbout Half of the TimeMost of the TimeAlwaysQV6_How often do you feel EnergeticNeverNeverOccasionallyAbout Half of the TimeMost of the TimeAlwaysQV7_How often do you feel GloomyNeverNeverOccasionallyAbout Half of the TimeMost of the TimeAlwaysQV8_How often do you feel AngryNeverNeverOccasionallyAbout Half of the TimeMost of the TimeAlwaysQV9_Do you have poor appetite or overeatNot at allNot at allSome daysEvery second dayNearly every dayQV10_Stress Percived Every day Selected Value: 0QV11_Have you ever won any competition?YESYESNOQV12_If Yes how many competition did u win? Selected Value: 0current treatmentsnoneif you are currently taking any medical or non-medical treatments, please let us know. Any treatment, even natural ones, may influence your hormone results.QS1_Body COP-DurationsecondsQS2_Body COP-FrequencyHerzQS3_Body COP-Ellipse Surfacemm2QS4_Body COP-Elbow LengthmmQS5_Body COP-Elbow Amplitude XmmQS6_Body COP-Elbow Amplitude YmmQS7_Mean Velocitymm/sQS8_Variance Velocitymm/sQS9_Average Accelerationmm/sQS10_Mean COP XmmQS11_Mean COP YmmQS12_LSFQS13_Left Foot_Mean PressurekPaQS14_Left Foot_Max Pressure kPaQS15_Left Foot_Surfacecm2QS16_Left Foot_Load% (Kg)QS17_Left Foot_Podalic AngleDegrees of Rotation (°)QS18_Left Foot_SCmmQS19_Left Fore Foot_Surfacecm2QS20_Left Fore Foot_Load% (Kg)QS21_Left Fore Foot_R/A%QS22_Left Back Foot_Surfacecm2QS23_Left Back foot_Load% (Kg)QS24_Left Back Foot_R/A%QS25_Right Foot_Mean PressurekPaQS26_Right Foot_Max PressurekPaQS27_Right Foot_Surfacecm2QS28_Right Foot_Load% (Kg)QS29_Right Foot_Podalic AngleDegrees of Rotation (°)QS30_Right Foot_SCmmQS31_Right Fore Foot_Surfacecm2QS32_Right Fore Foot_Load% (Kg)QS33_Right Fore Foot_R/A%QS34_Right Back Foot_Surfacecm2QS35_Right Back Foot_Load% (Kg)QS36_Right Back Foot_R/A%commentsnoneat this point you can provide us with any information not yet mentioned that you consider relevant so that the VitalizeDx team can deliver a personalized report that takes into consideration as much as possible of your personal data.SubmitSave and Resume LaterYour form entry has been saved and a unique link has been created which you can access to resume this form.Enter your email address to receive the link via email. 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