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  • Today's Date
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  • How can we help you?

  • Date of Birth*
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  • Format: (000) 000-0000.
  • Sex Assigned at Birth*

  • Breast and Ovarian Cancer

    BRCA 1 and BRCA 2 genetics test
  • Do you have a history of breast and/or ovarian cancer?*
  • Do you have a family history of breast and/or ovarian cancer?*
  • Have you already experienced menopause?*
  • Have you ever undergone hormone therapy?*
  • Do you use hair relaxer?*
  • How often do you self examine your breasts?*
  • Have you ever had radiotherapy and/or surgery on your breasts?*
  • Have you ever had a clinical breast examination?*
  • Are your breasts dense?*
  • Have you ever taken birth control?*
  • Have you ever had a pap smear?*
  • When was the last time you had a pap smear?*
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  • Colorectal Cancer

    Fecal Occult Blood Test (FOBT) and Colorectal Cancer Genetics Test

  • Insyte's colorectal cancer screening includes two important tests: the fecal occult blood test (FOBT) detects stool blood, indicating potential colorectal issues, while the colorectal cancer genetics test identifies genes associated with increased cancer risk. Your healthcare provider will recommend the most suitable test based on your specific needs.

  • Do you have family members and / or relatives that have history of colorectal cancer?*
  • Do you have personal history of colorectal cancer?*
  • Do you have history of having polyps in the colon or rectum?*
  • How often do you exercise?*
  • Do you consider yourself physically active?*
  • How often do you drink alcohol?*
  • Do you have history of inflammatory bowel disease?*
  • Do you have type 2 diabetes?*
  • Have you ever been diagnosed with breast, ovarian, uterine, pancreatic, or colorectal cancer?*
  • Have you ever been tested for colorectal cancer?*
  • If yes, when?*
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  • Prostate Cancer

    Prostate-Specific Antigen (PSA) Test and

  • Prostate cancer screenings at Insyte involve the prostate-specific antigen (PSA) test, which measures PSA levels in the blood to detect potential prostate issues, and the prostate cancer genetics test, examining specific genes associated with an elevated risk of developing prostate cancer. Your healthcare provider will recommend the most appropriate test based on your individual circumstances.

  • I experience problems when peeing*
  • Have you ever been tested for prostate cancer?*
  • I have a family history of prostate cancer*
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  • My age is within 40 to 69 years old*
  • My age is 70 years old or older, and I am only taking 1 prescription drug or no prescriptions at all*

  • Rate the following symptoms on how frequent you
    experience them:

  •

  • Thyroid Cancer

  • As a child or infant, have you ever been exposed to radiation to the head and/or neck?*
  • Have you been exposed to radiation as an adult?*
  • Do you have a family history of thyroid disease and/or thyroid cancer?*
  • Do you have a history of goiter (enlarged thyroid)?*
  • Have you ever been diagnosed with a genetic condition such as (MEN2), which is caused by a change in the RET gene?*
  • During your last routine physical exam, did the doctor find lumps (nodules) or swelling in the neck, voicebox, and lymph nodes, or anything else found in the neck that was unusual?*
  • Are you feeling any fatigue?*
  • Are you experiencing unexplained weight loss?*

  • Lung Cancer

  • Is your age within 50 to 80 years old?*
  • Have you smoked in the past 15 years?*
  • Have you stopped smoking?*
  • Have you been exposed to cancer causing chemicals?*
  • Do you have difficulty breathing or cannot take a deep breath?*
  • Are you able to be physically active without feeling lightheaded and without feeling like you have trouble breathing?*

  • Women's Reproductive Health

    Gonorrhea, Chlamydia, Trichomonas
  • Have you recently had unprotected sex?*
  • How long ago since you last had unprotected sex?*
  • Have you had more than 1 sexual partner in the past 12 months?*
  • Are you experiencing any pain while urinating?*
  • Do you see any discharge from your vagina?*

  • Sexual Health

    HIV 1/2 and Hepatitis-C (HCV)
  • Is your age within 13 to 65 years old when you take this test?*
  • Do you think that you have certain behaviors, factors, and/or actions that put you at risk for getting HIV?*
  • In the last year, have you had either vaginal or anal sex with: (Check all that apply)*
  • Do you have or have you had more than 1 sexual partner in the past year?*
  • Have you ever experienced the following:*
  • Before today, when was the last timeyou had an HIV test?*
  • What was the result of your last test?*

  • Respiratory Health

    Covid-19, Flu A/B, Strep-A
  • Are you experiencing any of these symptoms?*
  • Additionally, are you experiencing any of the following*
  • Have you been in contact with someone who has tested positive for COVID-19, has COVID-19 or is being evaluated for COVID-19?*
  • Have you tested positive for Covid-19 in the past 10 days?*
  • Are you currently awaiting results from a COVID-19 test?*
  • Have you been diagnosed with COVID-19 by a licensed physician in the last 10 days?*
  • Are you from or have you been in areas with a Covid-19 outbreak in the past 14 days?*
  • Have you traveled internationally for the past 14 days?*

  • RECEIVE YOUR TEST

    Please answer the following questions to ship the test / collection kit to your home
  • Are you a NEW PATIENT? (You have not received a test or sample collection kit from Insyte before)*
  • Do you already have a log-in access to Insyte's patient portal ("Onpatient")?*

  • Government-Issued ID

  • Image field 726

  • Examples:

    State Driver's License
    Passport
    Military ID
    Permanent Resident Card
    Tribal Card

  • Insurance

  • Image field 732

  • Your insurance card MUST have the following:

    1.) Insurance Company Name
    2.) Your Full Name
    3.) Identification Number as a Member / Subscriber / Policyholder

    If it does not have any of the following, this may delay the delivery of your tests, and you will be contacted to provide further information

  • HIPAA Release Form

  • By signing below, I authorize Insyte Biomed, LLC to disclose my complete health record including, but not limited to, diagnoses, lab test results, treatment, and billing records for all conditions, to any individual or organization duly assigned by Insyte Biomed, LLC for my care. My complete health record may be stored and disclosed in electronic copy or access via a web-based portal or by hard copy at my request, at the duration of the past, present, and future periods. 

    I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to: Insyte Biomed, LLC, 989 W. Kennedy Blvd. Ste 203, Orlando, FL 32810.

    I understand that:

    In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.


    I understand that I do not need to give any further permission for all my protected patient health records and information.


    I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.

  • NEW PATIENT REGISTRATION

  • Additional Patient Demographics

  • Are you Hispanic or Latino descent? (Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish Culture)*
  • Do you have a primary care physician?*

  • Medical History

  • Do you have any of the following conditions? (Select all that apply):*

  • Mental Health History

  • Do you have any of the following conditions? (Select all that apply):*
  • Do you have any allergies?*
  • Are you taking any medications?*
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  • Do you have trouble keeping up with your medication(s)?*

  • Medical History of Family and Relatives

  • Do any of your immediate family members and relatives have the following conditions? (select all that apply):*

  • Surgical History

  • Have you undergone any surgical operations on the following? (select all that apply):*
  • Have you ever injected or pumped silicone, oils, or other substances for the purpose of body shaping?*
  • Other than for surgery or childbirth, have you ever been hospitalized overnight for a medical or mental health issue?*
  • When was the last time you got hospitalized overnight? *
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  • Vaccination History

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  • Have you ever been tested for tuberculosis?*
  • What was the result?*
  • When was the last time you got tested for tuberculosis?*
     - -
  • Have you ever had a positive test for tuberculosis?*
  • If yes, did you complete 6 or more months of preventive treatment?*
  • Are you experiencing any of these symptoms?*
  • Have you had known contact with someone to have tuberculosis?*
  • Were you born in Asia, Africa, Latin America, or Eastern Europe?*
  • Have you spent more than 2 weeks in Asia, Africa, Latin America, or Eastern Europe in the past 2 years?*
  • Have you been in prison / jail in the past 5 years?*
  • Do you work with people who use drugs, are migrant workers, or are experiencing homelessness?*
  • Are you a healthcare worker?*

  • Sexual Health and Cancer Screenings

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  • Are you going to or planning to get screened for your sexual health through Insyte? (such as for HIV, gonorrhea, chlamydia, trichomonas)*
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  • What is your sexuality? (check all that apply):*
  • When was the last time you had sexual contact with another person?*
  • What is your relationship status?*
  • Have you ever been diagnosed with or tested positive for a sexually transmitted infection?*
  • If yes, please check all that apply:*
  • Do you currently have at least 1 sexual partner?*
  • Do you have more than 1 sexual partner at the moment?*
  • What is the gender of your sexual partner(s)? (Check all that apply):*
  • As far as you are aware, do any of your sexual partners (current and past) have had a chronic sexually transmitted infection? (HIV, Genital Warts, HPV, Herpes)*
  • Do you think you or your sexual partner(s) may have contracted a new sexually transmitted infection recently?*
  • Have you ever had a menstrual period?*
  • Do you still have regular periods?*
  • If no, are you on any medications that stop or affect your period? (such as hormones)*
  • Are you capable or have you ever been capable of becoming pregnant?*
  • Have you ever been pregnant?*
  • Did you experience any of the following?*
  • Are you planning on getting pregnant in the future?*
  • Do you or your partner(s) use any kind of birth control?*
  • If yes, what kind? (select all that apply):*
  • Are you satisfied with your birth control method(s)?*
  • Could you get pregnant today?*
  • Have you or are you currently going through menopause?*
  • Have you had any bleeding since then?*
  • Are you experiencing any symptoms of menopause?*
  • If yes, select all that apply:*

  • Mental Health and Substance Abuse Screening

  • Have you ever been non-consensually hit, slapped, kicked, or physically hurt?*
  • If yes, when approximately did this happen?*
     - -
  • Have you ever been forced or pressured to have sex?*
  • If yes, when approximately did this happen?*
     - -
  • Over the past two weeks, did you feel like having little interest or pleasure in doing things you usually enjoy?*
  • Over the past two weeks, did you feel down, depressed, or hopeless?*
  • Do you often have trouble sleeping?*
  • Do you currently use or have ever used tobacco products? (including vaping)*
  • Which best describes your status as a smoker?*
  • How often do you consume alcohol?*
  • In the past year, have you ever used recreational drugs or have used prescription medication for non-medical purposes?*
  • If yes, how often have you or did you do so in the past year?*
  • Select all that you have used in the past year:*
  • If you use opiods, do you have access to Narcan (naloxone)?*
  • Are you interested in quitting?*

  • Nutrition and Exercise

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  • How easy is it for you to access these foods?*
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  • Do you feel like you eat the right amount of food?*
  • Are you concerned about your weight?*
  • How many times per week do you exercise?*
  • Every time you exercise, how long do you do it?*

  • Employment, Housing, and Transportation

  • Are you working and/or in school? (select all that apply)*
  • What is your current living situation?*
  • Who do you live with? (select all that apply):*
  • Do you feel safe in your living situation?*
  • If you are over 50 and/or disabled, do you sometimes fall? Is it hard to get up?*
  • Are there guns in your home?*
  • Do you, your friends, or your family smoke in your home or place you live?*
  • Are there working smoke detectors in your home?*
  • Are you a primary caretaker for children, your parents or other adults?*
  • Do you have any pets or a support animal?*
  • When in a car, do you wear a seatbelt?*
  • When riding a motorcycle, do you wear a helmet?*
  • When riding a bicycle, do you wear a helmet?*
  • Have you had any transportation-related accidents recently?*
  • Are family members/friends worried about you driving?*

  • Gender History

  • Are you transgender, non-binary, gender non-conforming or have a history of gender transition?*
  • What is your gender identity? (select all that apply)*
  • Have you ever felt anxious, depressed, or suicidal because your physical appearancedoes not align with your gender identity?*
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  • Have you changed your name and/or gender marker on all of your identity documents?*
  • If no, do you want to update any of your identity documents?*
  • If yes, which documents would you like to update?*
  • What would you like to change?*
  • Do you use any prosthetics or compression techniques to express your gender?*
  • Which prosthetic do you use?*
  • Are you experiencing any of these complications with the prostethics?*
  • Have you ever discussed medical transition (hormone therapy and/or surgery) with a health care provider before?*
  • If yes, when were you first diagnosed with gender dysphoria?*
     - -
  • Are you currently undergoing hormone therapy?*
  • When did you first start hormone therapy?*
     - -
  • Rows
  • Were you on hormones therapy in the past?*
  • If yes, Are you interested in starting or re-starting hormone therapy?*
  • Are you interested in pursuing any gender affirming surgeries?*
  • If yes, which surger(ies)? (Check all that apply)*

  • Attestation

  • By signing below, you agree to all terms and conditions set forth by Insyte Biomed, LLC, particularly but not limited to, the company's policies on HIPAA, the No Surprises Act, Returns and Exchanges, and Privacy

  • I would like to subscribe to the communications, educational materials, and other promotions of Insyte Biomed and its affiliates*
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