Ageing factors

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On-line Consultation

Attention, this free consultation is meant to provide you with an orientation regarding therapeutic opportunities. This could in no way replace a face-to-face consultation, that has always to take place. The data you will transmit will be processed in a strictly confidential way and will be used to no other purpose than your information.

For an consultation about wrinkles and aesthetic, click here.



Anti-age consultation.

- Personal data

Name :
Sex :
City :
Telephone :
First name :
Age :
Country :
E-mail :


- Personal data


Size : (cm)
Smoker : no yes
Weight : (Kg)
From : (years)



Answer with a value from 1 to 4
1 = never
2 = a little
3 = moderately
4 = much

- General questions

Have you?

memory trouble ? 1    2    3    4   
lost weight ? 1    2    3    4   
lost appetite ? 1    2    3    4   
articular pains ? 1    2    3    4   
dry eyes, dry skin ? 1    2    3    4   
a tendency to gain stomach ? 1    2    3    4   
muscle loosening ? 1    2    3    4   
difficulty in recovering after an effort ? 1    2    3    4   
digestive problems ? 1    2    3    4   
difficulty in getting up ? 1    2    3    4   
a tendency to gain weight ? 1    2    3    4   
frequent waking up at night ? 1    2    3    4   
the impression to seem older than you are ? 1    2    3    4   
a slow reflection ? 1    2    3    4   
difficulty in tanning ? 1    2    3    4   
anxiety ? 1    2    3    4   
a tendency to lose mass of hair ? 1    2    3    4   
difficulty in reacting to stress ? 1    2    3    4   
a tendency to allergies ? 1    2    3    4   
dropping eyelids ? 1    2    3    4   
loose and thin face skin ? 1    2    3    4   
tiredness at night and in the periods of stress during the day ? 1    2    3    4   
tiredness when resting that disappears with activity ? 1    2    3    4   
stiff articulations when you get up in the morning ? 1    2    3    4   


- Questions devoted to men


Have you ?
a loosened, wrinkled face ? 1    2    3    4   
a lack in vital energy ? 1    2    3    4   
a drop in libido ? 1    2    3    4   
gynecomasty (fat in the breast) ? 1    2    3    4   
a lack of self-confidence ? 1    2    3    4   
a decrease in your sexual performances ? 1    2    3    4   



- Questions devoted to women

Have you ?
vertical wrinkles around the mouth ? 1    2    3    4   
too much pilosity in the face ? 1    2    3    4   
irritated and dry eyes ? 1    2    3    4   
hot flush ? 1    2    3    4   
permanent tiredness ? 1    2    3    4   
a tendency to depression ? 1    2    3    4   
a lack of sexual appetite ? 1    2    3    4   
abundant periods ? 1    2    3    4   
nervosity and irritability ? 1    2    3    4   
anxiety ? 1    2    3    4   
a disturbed sleep ? 1    2    3    4   
regular periods ? 1    2    3    4   
a tendency to anger crises ? 1    2    3    4   
a loosened and wrinkled face ? 1    2    3    4   
a tendency to accumulate fat at the abdomen level ? 1    2    3    4   
a drop in libido ? 1    2    3    4   
fat accumulated in saddlebag thighs ? 1    2    3    4   


- Free zone

Remarks or particular ageing signs to be mentioned

 

AntiAgeSolutions | Chaussée d'Alsemberg, 995 - 1180 UCCLE | 19, Cour Saint-Antoine 4000 - Liège | (32) 02 647 59 30
contact@antiagesolutions.be
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