Health Intake Questionnaire

Takes 1 Min To Complete

What concerns would you like to address? *

What Is Your Primary Concern?

How long have you been experiencing fatigue

Do you wake up feeling refreshed?

Energy crashes during the day

Which symptoms accompany your fatigue most? (select all applicable) *

What has been the most frustrating about your weight/metabolism?

Where do you tend to gain weight most?

Have you tried dieting or exercising

Have you ever been told you may have:

Which symptoms concern you the most? (Select all applicable) *

Have symptoms gradually worsen over time?

Have you previously had hormone testing?

Have you ever tried any of the following? (Select all applicable)

When is brain fog typically worst?

Which symptoms affects you the most? (Select all applicable) *

Do you feel mentally exhausted even after sleeping?

Does caffeine significantly improve your systoms?

Which digestive symptoms do you experience most often? (Select all applicable) *

How frequently do symptoms occur?

Have you previously tried? (select all applicable)

Do symptoms worsen after eating?

Which best describes your sleep concerns?

How many hours of sleep do you average nightly?

Do you rely on any of the following for sleep? (Select all applicable)

Do you snore or suspect sleep apnea?

Have you been diagnosed with any of the following? (select all applicable)

Which symptoms affects you the most? (Select all applicable) *

Do symptoms seem connected to? (Select all applicable)

Have symptoms been:

What are you most hoping to optimize?

Are you primarily looking to:

Have you previously invested in any of the following: (Select all applicable)

How important is proactive health optimization to you?

Previous Labs In Last 12 Months

On Any Current Medications

Any Past Diagnosis?

What Best Describes You Right Now *

If We Identified Root Cause, Would You Be Open To Advanced Testing *

Full Name *

Email *

Phone *

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