Lab Intake Form

Lab Intake Form

We need your responses to order labs. Thank you!
Name*

First NameLast Name
Social Security Number
You can call me with this if you wish not to write it here.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Sex at Birth*

MaleFemale
Gender Identity*

Choose not to discloseFemaleMaleFemale-to-Male/Transgender Male/Trans ManMale-to-Female/Transgender Female/Trans WomanGenderqueer, neither exclusively male nor femaleAdditional gender category or other
Sexual Orientation*

Choose not to discloseBisexualLesbian, gay, or homosexualStraight or heterosexualSomething elseDon't know
Ethnicity*

Choose not to discloseHispanic or LatinoNon-Hispanic or Non-LatinoOtherUnknownAsked but unknown
Race*

Choose not to discloseAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
Weight (lbs.)*
Height (ft.)*
Waist circumference (in.)
WAIST
Hip circumference (inches)
HIP
Body fat percentage
Resting heart rate
While at rest, find your pulse (either your inner wrist or neck) and count the number of beats for 30 seconds. Then multiply that number by 2.
Do you follow a particular diet?*

Gluten FreeKetogenicMediterraneanPaleoVeganVegetarianNoneOther
Let's look at your diet a bit closer now. What foods do you eat, and how ofter?

If there is a food you eat but wish to exclude from your recommendations, select “Never” — we will not recommend foods marked “Never.”
Fruits
Vegetables
Nuts
Grains
Beans
Soy
Dairy
Eggs
Fish
Poultry
Shellfish
Pork
Deli meats
Breakfast meats
Red meats
Eatery/Takeout
Gluten-free grains
Now, what about beverages? Which ones do you drink, and how often?
Soda
Sports drinks
Caffeine
Alcoholic
Sweet (including juice)
Sweet (including juice)
How often do you eat at restaurants or get take-out?

This does not include meal subscription services like Blue Apron or HelloFresh
I eat out/get take-out...
Let's shift over to supplements real quick
Would you like to receive supplement recommendations?

YesNo
Do you currently take supplements?

YesNo
Do you require NSF Certified for Sport supplements only?

YesNo
Which supplements do you currently take?

B ComplexCalciumCreatineFish OilIronMagnesiumMultivitaminProbioticsProteinVitamin B12Vitamin CVitamin DAlpha-Lipoic AcidArtichoke Leaf ExtractAshwagandha rootChromiumCinnamonCitrulline MalateCollagenConjugated Linoleic AcidCoQ10Folic AcidGarlicGingerGinsengGreen Tea ExtractHesperidinIsoflavoneLuteinMelatoninMK-7PeppermintPlant SterolsPropolisResveratrolRhodiolaSpirulinaVitamin E
Now just a few more questions to wrap up.
Which exercises do you do on a weekly basis?

I don't exerciseEndurance TrainingResistance TrainingClasses & FlexibilitySports
How much sleep do you get per night?
Include hours and minutes
What is your total daily exposure to the sun?

Less than 20 minutes20+ minutes
Do you smoke tobacco products?

YesNo
What do you want to focus on?

EnduranceImprove CognitionHealthy agingOverall HealthLose FatMetabolismHeart HealthGut HealthInjury Prevention / RecoverySleepImmunityStrength and PowerStressEnergy
Should be Empty:

Lab Intake Form

Let's look at your diet a bit closer now. What foods do you eat, and how ofter?

Now, what about beverages? Which ones do you drink, and how often?

How often do you eat at restaurants or get take-out?

Let's shift over to supplements real quick

Now just a few more questions to wrap up.