Benutzeranlage-NBF-ENG

First name*

Last name*

E-mail address*

Mobile phone number*

Desired PIN for your profile (4-digit number)*

Which language would you like to use in the NeuroBodyGym surface?*

GERMAN
ENGLISH
SPANISH

Date of birth*

Height in cm*

Body weight in kg*

Are any diseases known? If yes, please fill in.

Are you taking any medication? If yes, please fill in.

Have you had any problems or negative reactions to a medical procedure or vaccination during the last 12 months? If yes, please describe briefly.

Do you wear glasses or contact lenses?*

No
Glasses for reading only
Glasses wearer
Contact lens wearer

Do you smoke? If yes, how often and how much?

How often do you drink alcohol?*

Never
1 time a week
2-3 times a week
more than 3 times a week

Have you taken any drugs during the last 12 months? If yes, which ones?

What time do you usually go to bed?*

Do you use aids such as sleeping pills? If yes, which ones?*

Please select the appropriate statement from the following:

I am easily distracted…*

I am a ponderer…*

I quickly loose my temper when I am frustrated or when something doesn’t work out…*

I can quickly trust other people…*

I can already feel the physical effects of my high workload like for example tension, tiredness, listlessness – also sexually, sweating, high pulse, headaches…*

I can fall asleep easily…*

I sleep well…*

I am rested and full of energy in the morning…*

Have you already received the NBF starter kit?*

Yes
No

* Pflichtfelder