{"id":2746,"date":"2023-05-08T11:07:10","date_gmt":"2023-05-08T08:07:10","guid":{"rendered":"https:\/\/www.anasa.com.gr\/erotimatologio-enilikon\/"},"modified":"2023-08-02T13:47:31","modified_gmt":"2023-08-02T10:47:31","slug":"adult-questionnaire","status":"publish","type":"page","link":"https:\/\/www.anasa.com.gr\/en\/adult-questionnaire\/","title":{"rendered":"Adult Questionnaire"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2748-o1\" lang=\"el\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/2746#wpcf7-f2748-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2748\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.7.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"el\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2748-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"uacf7-form-2748\"><div class=\"erothmatologio-efhvon vc-border\">\n\n<div class=\"vc-row \">\n\t\t\t\t<div class=\"vc-col-12 vc-text-center mb-40\"><h4> ADULT QUESTIONNAIRE<\/h4><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-12 vc-text-right\"><label> DATE: <span class=\"wpcf7-form-control-wrap\" data-name=\"date-form\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date date-form\" min=\"2026-05-08\" max=\"2026-05-08\" step=\"3\" aria-required=\"true\" aria-invalid=\"false\" value=\"2026-05-08\" type=\"date\" name=\"date-form\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20\">\n\t\t\t\t<div class=\"vc-col-6\"><label> PHONE NUMBER: <span class=\"wpcf7-form-control-wrap\" data-name=\"tel-epikoinonias\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"tel-epikoinonias\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-6\"><label> EMAIL: <span class=\"wpcf7-form-control-wrap\" data-name=\"email-epikoinonias\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email-epikoinonias\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-12\"><label>FULL NAME: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-onomateponumo\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-onomateponumo\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n<!-- \t\t\n\t\t<div class=\"vc-row mb-40 mt-20\">\n\t\t\t\t<div class=\"vc-col-12\"><p class=\"vc-text-center\">\u03a0\u03b1\u03c1\u03b1\u03ba\u03b1\u03bb\u03ce \u03c3\u03c4\u03b7 \u03c3\u03c5\u03bd\u03ad\u03c7\u03b5\u03b9\u03b1 \u03bd\u03b1 \u03b1\u03c0\u03b1\u03bd\u03c4\u03ae\u03c3\u03b5\u03c4\u03b5 \u03c3\u03c4\u03b1 \u03c0\u03b1\u03c1\u03b1\u03ba\u03ac\u03c4\u03c9 \u03b5\u03c1\u03c9\u03c4\u03ae\u03bc\u03b1\u03c4\u03b1<\/p><\/div>\n\t\t<\/div> -->\n\t\t\n\t\t\t\t<div class=\"vc-row vc-border-b\">\n\t\t\t\t<div class=\"vc-col-4\"><label> AGE<span class=\"wpcf7-form-control-wrap\" data-name=\"text-ilikia\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input field-ilikia\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-ilikia\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-4\"><label> SEX<span class=\"wpcf7-form-control-wrap\" data-name=\"text-fulo\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input field-fulo\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-fulo\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-4\"><label> DO YOU HAVE INSUR-ANCE?<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-asfalisi\"><span class=\"wpcf7-form-control wpcf7-radio vc-field-radio field-asfalisi\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-asfalisi\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-asfalisi\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/span><\/span><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-12\"><label>WHERE DID YOU LEARN ABOUT US? <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-pou-mathate-tin-anasa\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-pou-mathate-tin-anasa\"><\/textarea><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-6\"><label>WHAT KIND OF PROBLEMS DO YOU FACE? <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-provlima\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-provlima\"><\/textarea><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-6\"><label>SINCE WHEN? <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-pote-xekinise-to-provlima\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-pote-xekinise-to-provlima\"><\/textarea><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-6\"><label>WEIGHT: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-varos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-varos\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-6\"><label>HEIGHT: <span class=\"wpcf7-form-control-wrap\" data-name=\"text-ipsos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-ipsos\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row\">\n\t\t\t\t<div class=\"vc-col-12\"><label>HAVE YOU LOST WEIGHT IN THE PAST? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-xanei-varos-sto-parelthon\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-xanei-varos-sto-parelthon\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-6\"><label>HOW MUCH? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-poso-varos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-poso-varos\" \/><\/span><\/label><\/div>\n\t\t\t\t<div class=\"vc-col-6\"><label>IN WHAT WAYS?  <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-tropoi-meiosis-varous\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-tropoi-meiosis-varous\"><\/textarea><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row\">\n\t\t\t\t<div class=\"vc-col-12\"><label>DO YOU HAVE EPISODES OF BINGING? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-epeisodia-uperfagias\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-epeisodia-uperfagias\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row\">\n\t\t\t\t<div class=\"vc-col-12\"><label>HOW MANY EPISODES PER DAY? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-suxnotita-uperfagias\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-suxnotita-uperfagias\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-20 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-12\"><label>PLEASE DESCRIBE AN EXAMPLE OF A BINGING EPISODE: <span class=\"wpcf7-form-control-wrap\" data-name=\"textarea-paradeigma-uperfageias\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required vc-textarea\" aria-required=\"true\" aria-invalid=\"false\" name=\"textarea-paradeigma-uperfageias\"><\/textarea><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-20\">\n\t\t\t\t<div class=\"vc-col-12\"><label>DO YOU TAKE LAXATIVES? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-xrisi-kathartikon\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-xrisi-kathartikon\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-40 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-12\"><label>DO YOU VOMIT? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-kanete-emetous\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-kanete-emetous\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-40 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-12\"><label>DO YOU HAVE GYNECOLOGICAL PROBLEMS? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-gunaikologika-provlhmata\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-gunaikologika-provlhmata\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-40 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-12\"><label>HOW DO YOU FEEL ABOUT YOUR BODY? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-pos-niothete-me-to-soma-sas\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-pos-niothete-me-to-soma-sas\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-40 vc-border-b\">\n\t\t\t\t<div class=\"vc-col-12\"><label>HAVE YOU BEEN OBSERVED BY A PSYCHIATRIST OR A PSYCHOLOGIST IN THE PAST? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-parakolouthisi-psyxologou\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required vc-field-input vc-field-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-parakolouthisi-psyxologou\" \/><\/span><\/label><\/div>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"vc-row mb-40\">\n\t\t\t\t<div class=\"vc-col-12\">\n\t\t\t\t\t\t<p>I confirm the accuracy and legitimacy of the above data which I filled in <span class=\"wpcf7-form-control-wrap\" data-name=\"date-end\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date date-form\" min=\"2026-05-08\" max=\"2026-05-18\" step=\"0\" aria-required=\"true\" aria-invalid=\"false\" value=\"2026-05-08\" type=\"date\" name=\"date-end\" \/><\/span> and I sign. <\/p>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mt-60\">\n\t\t\t\t<div class=\"vc-col-4\">\n\t\t\t\t\t\t<hr>\n\t\t\t\t\t\t<p>Name and Signature<\/p>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mt-20\">\n\t\t\t\t<div class=\"vc-col-12\">\n\t\t\t\t\t\t<span>(Note: This completed form will be given to you for signature when you visit ANASA at your 1st appointment)<\/span>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mt-60\">\n\t\t\t\t<div class=\"vc-col-12\">\n\t\t\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-448\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-448\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I confirm that I am over 18 years old<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-40\">\n\t\t\t\t<div class=\"vc-col-12\">\n\t\t\t\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-618\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-618\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I have read the <a href=\"https:\/\/www.anasa.com.gr\/en\/notification-statement-of-consent-adult\/\" target=\"_blank\">Notice<\/a> on the collection and processing of personal data and by submitting my details, I declare my consent.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row mb-20\">\n\t\t\t\t<div class=\"vc-col-12\"><p><strong>Subsequently, the clinical team of ANASA will receive the completed questionnaire, evaluate it and the Secretariat of DC ANASA will call you to schedule the 1st appointment with a specialist of our Center.<\/strong><\/p><p><strong>\nThank you very much and we will contact you soon!<\/strong><\/p><\/div>\n\t\t<\/div>\n\t\t<div class=\"vc-row\">\n\t\t\t\t<div class=\"vc-col-12\"><input class=\"wpcf7-form-control has-spinner wpcf7-submit vc-field-submit\" type=\"submit\" value=\"SUBMISSION\" \/><\/div>\n\t\t<\/div>\n\t\t\n\t\t<\/div><\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":6,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"acf":[],"_links":{"self":[{"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/pages\/2746"}],"collection":[{"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/comments?post=2746"}],"version-history":[{"count":3,"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/pages\/2746\/revisions"}],"predecessor-version":[{"id":2751,"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/pages\/2746\/revisions\/2751"}],"wp:attachment":[{"href":"https:\/\/www.anasa.com.gr\/en\/wp-json\/wp\/v2\/media?parent=2746"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}