Symptom Assessment

Personal Information* This field is required.

Full Name

Date of Birth

Age

Sex assigned at birth

Please enter your email

Have you been diagnosed with, experienced, or undergone any of the following:Please tick all that apply. If not included on the list, please select "Other" and type in the condition/s.

Anemia

Anorexia

Anxiety / Depression

Breast Implants

Carpal tunnel syndrome

Chronic Fatigue

Diabetes Type 1

Diabetes Type 2

Endometriosis

Gall Bladder Removed

Graves Disease

Hashimotos

Hiatus Hernia

Other Thyroid Conditions

IBS

IBD

Polycystic Ovary Syndrome

Root Canal

Seizures

Trigeminal neuralgia

Ulcers (stomach)

Hypothalamic Amenorrhea

Fibroids

Adenomyosis

Other/s

None

How were you diagnosed with Hypothalamic Amenorrhea?Please tick all that apply.

Bloodwork

Ultrasound

Specialist

How were you diagnosed with Fibroids?Please tick all that apply.

Bloodwork

Ultrasound

Specialist

How were you diagnosed with Adenomyosis?Please tick all that apply.

Bloodwork

Ultrasound

Specialist

Other you have been diagnosed with, experienced, or undergone

Have you ever been tested for Helicobacter (H. Pylori)?

YESNO

What was the result?

POSITIVENEGATIVE

Did you undergo any therapy/treatment?

YESNO

What therapy/treatment did you undergo?

UPPER GASTROINTESTINAL SYSTEMPlease tick all symptoms that apply.

Belching after eating

Bloating in stomach region

Heartburn or acid reflux

Feel excessively heavy after eating meat

Feel better if you skip meals

Fragile fingernails

Brittle hair/hair loss

Diarrhea after eating

Undigested food in stools

Frequent use of PPI's or antacids

Aversion to eating meat (not due to ethical reasons)

Discomfort when swallowing tablets

History of H Pylori infection

Bad Breath

Frequent Hiccups

Rosacea

Indigestion

Persistent Cough

Esophageal/diaphragm spasms

LIVER AND GALLBLADDERPlease tick all symptoms that apply.

Pain between shoulder blades

Stomach upset by fatty foods

Loose stools or oily substance in toilet water

Motion sickness

Get easily hungover if you drink alcohol

Sensitive to chemicals / perfumes

Chronic fatigue or lethargy

Gallbladder removed

General itchiness/itchy palms

Feel full for an extended period of time after eating fats

Feel sluggish after consuming fats

SMALL INTESTINES / MICROBIOMEPlease tick all symptoms that apply.

Bloating after eating (around belly button region)

Food allergies/sensitivities

Hay fever, congested sinuses or seasonal rashes

Diarrhea or loose stools

Constipation

History of food poisoning or traveler's bug (even if once off)

History of UTI's

Dry eyes or mouth

Nerve pain

Pins and needles or sleeping limbs

Brittle hair / fingernails

Poor facial skin tone (e.g. looking washed out)

Poor exercise tolerance (e.g. bad muscle soreness)

Joint Pain/Neck Stiffness/Knee Pain/Finger Pain

Tooth or Mouth Sensitivity

Known food sensitivities or triggers?If none, type in "None".

LARGE INTESTINES/ACETALDEHYDEPlease tick all symptoms that apply.

Coating on your tongue

Bloating lower down (below belly button)

Itchy Inner Ears

Anus or Vaginal itching

Taken more than 5 courses of antibiotics in your life

History of fungal or yeast infections (including athlete's foot)

Jock itch, dermatitis, or fungal rashes

Flakey skin on bottom of feet / heels

Excessively bad smelling gas

Frequently pass gas

Born via caesarean section

Stomach cramps

Itchy Scalp/Dandruff

Anxiety or low motivation

Overly sensitive to alcohol

Lethargy/fatigue

Blood in stool

Sugar Cravings

BLOOD SUGARPlease tick all symptoms that apply.

Awaken during the night

Crave sweet foods

History of binge eating

Irritable if going long periods between meals

Frequent thirst or urination

Headaches or blurred vision between meals

Shaky between meals

Eating relieves fatigue

Eating causes fatigue

History of diabetes in family

Restless Legs Syndrome

ADRENAL FUNCTIONPlease tick all symptoms that apply.

Difficulty falling asleep

Difficulty waking up or getting going in the morning

History of high or low blood pressure

Grinding teeth at night

Chronic back or knee pain

Become dizzy when standing suddenly

Crave salty foods

Emotionally traumatic events in the past

THYROID FUNCTIONPlease tick all symptoms that apply.

Easily fatigued or sleepy during the day

Difficulty waking up or getting going in the morning

Sensitive to cold temperatures

Constipation

Hair loss or thinning eyebrows

Poor short term memory

Diagnosed with thyroid condition

Consistently low mood

Currently on the birth control pill

Don't use a fluoride water filter for drinking

History of Epstein Barr Virus

WOMEN'S HEALTHPlease tick all symptoms that apply.

PMS

Binge eating episodes or sugar cravings around periods

Heavy or painful menstrual flow

Skipped periods

Variation in menstrual cycle length

Painful intercourse

Store most of your body fat around your hips or glutes

Excessive facial or body hair

Hot flashes or night sweats

Acne

History taking birth control

Nickel allergy (including earrings)

Blood clots

Light bleeding (barely use sanitary products)

ENVIRONMENTAL FACTORSPlease tick all that apply.

Do you live next to power lines or industrial plants

Do you work with chemicals or petroleum

Have you lived or worked in buildings with mold

Do you NOT use a water filter for drinking

Is there a Wi-Fi router in your bedroom

Have you had mercury fillings

Do you NOT stand barefoot outdoors or on cement daily?

How many hours of natural light are you exposed to each day?

SEROTONINPlease tick all that apply.

Depression

Anxiety

Seasonal Depression

Difficulty falling asleep

Highly sensitive to pain

Prone to obsessive behaviours

Loss of enjoyment of hobbies

Social Phobias

Mood Swings

DOPAMINEPlease tick all that apply.

Depression

Poor concentration or focus

Poor Balance

Low energy

Sleep too much

Tendency towards addictive behaviours

GABAPlease tick all that apply.

Anxiety

Insomnia

Panic attacks

Muscle tightness

Use food, alcohol, or tobacco to calm down

Did you train in the 48 hours prior to these blood tests?

Yes

Unsure

How many litres of water do you consume in an average day?

Do you currently take any prescription medication?This includes any contraceptive medication.

YESNO

What type, why, what dosages, and how long have you taken it for?* This field is required.

Testosterone & Hormonal SymptomsPlease tick all symptoms that apply.

Low libido / reduced sexual desire

Erectile dysfunction or weak erections

Reduced morning erections

Decreased muscle mass or difficulty building muscle

Fat gain around abdomen or chest

Fatigue or low stamina

Mood swings, irritability, or depression

Difficulty concentrating / "brain fog"

Hair thinning or loss (especially on scalp or body)

Reproductive & Fertility HealthPlease tick all symptoms that apply.

Have you ever had a semen analysis?

Low sperm count or motility (if known)

History of varicocele or undescended testicle

Prostate enlargement or urinary difficulty

Pain or discomfort in testes or scrotum

History of STIs or chronic prostatitis

Lifestyle Factors Impacting Male HealthPlease tick all symptoms that apply.

Do you use anabolic steroids or testosterone replacement therapy?

Do you frequently consume alcohol (more than 5 drinks/week)?

Do you vape or smoke?

Do you use saunas, hot tubs, or tight underwear daily?

Have you experienced chronic stress or trauma?