Participant Brief Questionnaire - Restoration of the Family in the Age of Aquarius

✅ Thank you! Your data has been received.
The blog author will see it soon!
He will create a personal plan shortly and send you a download link

⚠️ ATTENTION! READ BEFORE FILLING OUT: This brief is not a medical record, and the blog author is not a doctor.

This method is suitable ONLY for disciplined individuals without medical contraindications.

If you are looking for a way to “quickly lose weight for the summer” without effort or want someone else to take responsibility for your health — please close this page. This course requires iron discipline and complete personal responsibility.

Section 1: Your Readiness and Responsibility

1. Confirmation of Absence of Contraindications

Check the boxes if the statement is true for you:

I do NOT have type I diabetes

I am NOT pregnant and not breastfeeding

I do NOT have active tuberculosis

I do NOT have severe heart rhythm disorders

I do NOT have malignant tumors

I do NOT have a body weight deficiency (cachexia)

2. Understanding the Format

I understand that the blog author shares PERSONAL experience and recommendations, not medical treatment

I realize that any changes in my diet and daily routine are my personal choice and responsibility

I understand that the result depends 100% on my discipline and strict adherence to the rules

Section 2: About You

For statistics and tracking

Name *

E-mail *

for sending the personal plan

Age *

City *

Your Initial Data (Point A)

These numbers are needed for YOU to compare with the result

Weight (kg) *

Height (cm) *

Waist Circumference (cm) *

Blood Pressure (working) *

Format: systolic/diastolic (e.g., 120/80)

Section 3: Your Goals and Motivation

5. Why did you decide to take this course?

An honest answer will help you stay on track

I want to test my willpower and discipline

I need to “restart” my body and cleanse the receptors

I want to lose excess weight

I have health issues that I want to address

Additional Details *

6. Are you ready for challenges?

Fasting is not a vacation. There will be crises, weakness, and the desire to give up

How do you rate your discipline from 1 to 10? *

Do you have the opportunity to walk for 2-3 hours a day (mandatory condition)? *

Yes, I can do it daily

No, I can’t do it right now

Will you be able to ensure a calm environment at home? *

Yes, completely

No, there will be distractions

Section 4: Agreement on Information Support and Responsibility

Agreement Text:

I confirm that I am voluntarily starting the food pause course, being of sound mind.

I understand and agree that:

The blog author does not provide medical services.
The fasting and exit plan that I will receive is generated by artificial intelligence (neural network) based on open data about Professor Yu.S. Nikolaev’s methodology and my answers in this brief.
The blog author acts only as an operator who helps formulate the request to the neural network correctly, but does not guarantee the medical accuracy of the recommendations received.
I independently assess the risks and make the decision to follow the received plan.

I fully release the blog author from any responsibility for possible consequences related to my well-being and agree not to make any financial or legal claims.

I ACCEPT THE TERMS AND TAKE FULL RESPONSIBILITY FOR MYSELF

Section 5: For the Blog (optional)

8. Would you like to share your result?

We can publish your “Before/After” story (anonymously or openly) to inspire others

Yes, I don’t mind publishing my results

No, I am taking the course confidentially