Renew U DNA 360 Consultation Form

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

How would you describe your current wellness journey? (Multiple choice – choose one)*

I’m struggling and looking for answersI feel okay but know I could feel betterI’m mostly healthy but want to optimize and prevent issuesI’m doing this for my kids or familyI’m proactive and love learning more about my body

Concern #1: *

Concern #2:*

Concern #3:*

Which of these areas are most important to you right now? (Checkbox – select all that apply)*

What would success look like for you with this testing and consultation? What’s the change or clarity you’re most hoping for as a result of learning your genetic blueprint?*

Which best describes your current eating habits? (Select all that apply)

Do you have any known dietary restrictions or intolerances?

What type(s) of physical activity do you currently engage in? (Select all that apply)

How many days per week do you exercise?

01–23–45+

Average length of each workout?

Less than 30 minutes30–60 minutesOver 60 minutes

Please list all prescription medications you currently take. Include the name, dose, and frequency.

Please list all supplements you are currently taking. Include the brand, dosage, and how often you take them.

Test Kit Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

"Please note, many carriers do not successfully ship orders to PO Box. It is preferred to use a full shipping address. If you do continue with a PO Box your order may be delayed or not arrive, and another order will need to be placed"

Disclaimer & Acknowledgement
The information you provide in this form will be used to develop your consultation and personalized Road Map. This process is designed to guide your wellness journey using insights from functional genomics.

All information and recommendations are educational in nature and are not a substitute for medical care. I am a Registered Nurse and Functional Genomics Certified Practitioner, but I am not a medical doctor. Always consult your licensed healthcare provider before making changes to your diet, supplements, medications, or therapies.

Services and supplement recommendations are optional and must be individualized based on your medical history, prescriptions, and testing results.

Please note: AI-assisted tools are used to support the development of your personalized Road Map. This allows me to provide the most detailed, accurate, and practical recommendations possible. If for any reason you do not want your data included in AI-assisted processes, please submit this request in writing before your consultation.

I have read and acknowledge the above disclaimer.

DNA 360 Consultation Form

Top 3 Health Concerns (for your Road Map):