OPTIMAL HUMAN.

OPTIMAL HUMAN.

Elite Health and Longevity Protocols. Client Intake Form.
Basic Information

Please complete all required fields prior to phone, or in person consultation.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Age
Height (inches or cm)
Weight (lbs or kg)
Location (City, State/Province, Country)
Goals
Select your goals

Other
Current issues or symptoms (for example fatigue, joint pain, poor sleep, low libido, brain fog, stress or weight gain etc)
Health History
Describe your health history (diagnoses, surgeries, major illnesses, etc.) Have you ever been diagnosed with cancer, are you currently undergoing treatment, or are you in remission? If yes, please provide details (type, date diagnosed, treatment status, remission status, etc.).
List any current medications and supplements you are currently taking.
Lifestyle
Describe your typical sleep patterns (hours, quality, issues)
Describe your exercise habits (type, frequency, duration)
Describe your usual diet (meals, restrictions, preferences)
Substance Use
Do you currently smoke?
Do you consume alcohol?
Which compounds are you interested in ? (For example BPC 157, GLP3, Tesamoralin, Mots-C etc)
Helps me understand your interests.
Do you currently have any injuries ? If so what are they?
*IF you have recent lab work or blood test results and would like me to review them, please email them to OPTIMALHUMAN.CO@GMAIL.COM
Who referred you, or how did you hear about Optimal Human.
Acknowledgment

I confirm the information provided is accurate. I understand the is educational coaching and not medical advice. I accept full responsibility for my decisions.
RUO DISCLAIMER
I understand that all the information provided through Optimal Human is for educational purposes only. I understand that this service does not provide any medical advise, diagnosis, treatment, or prescriptions and is not a substitute for care from a licensed halthcare provider. I acknowldege that any compounds discussed including peptides may be classified as RESEARCH USE ONLY substances and may not be approved for human consumption by regulatory authorities. I understand no specific protocols, dosing instructions, or medical recommendations are being prescribed.
Acknowledgment and Agreement.
Digital Signature
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OPTIMAL HUMAN.

Basic Information

Goals

Health History

Lifestyle

Substance Use

Acknowledgment

RUO DISCLAIMER