Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name of Operator *FirstLastEmail *Athlete'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_ApertureNormalReducedQV1_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 sleep QV4_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: 0 QV11_Have you ever won any competition?YESYESNOQV12_If Yes how many competition did u win? Selected Value: 0 current 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.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.Submit Notice: JavaScript is required for this content.
