GENERAL INFORMATION SHEET

Page 1 of 2

1. General Information Sheet (Time: About 10 minutes)

2. Symptoms Checklist (Time: Less than 5 minutes)
General Information Form
Thank you for taking the time to provide us with your health history! Please type your answers into the form below. All information is encrypted and can only be accessed with a private key, which is held on my personal computer.
Name*
Today's Date

MonthDayYear
Date
Age*
Sex*

MaleFemale
Phone Number*
City & State*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Occupation
Height (feet, inches) *
Weight (lbs)*
Type of Hair Submitted*

HeadBeardPubicOther
How did you hear about us?
HEALTH HISTORY
What are your main health concerns or conditions?*
Please list any medications or food supplements you are currently taking:
Please list any imbalances found on RECENT medical test results (e.g. "low testosterone")
Upload any recent lab tests:

Cancelof
List past surgeries or hospitalizations with dates:
Please list any illness in your family such as cancer, diabetes, heart disease, etc.
WHAT'S YOUR DIET LIKE?
What are examples of typical breakfasts for you? (Please list actual foods).*
Mid-morning snacks:
Morning Beverages:
What are examples of typical lunches for you?
Mid-afternoon snacks:
Afternoon Beverages:
What are examples of typical dinners for you?*
Evening snacks:
Evening Beverages:
How often and what kind of exercise do you do?
How many hours of sleep do you get per day?*
Is there any other information that you'd like us to know about?
Please continue to the SYMPTOMS CHECKLIST on the next page.

General Information Form

HEALTH HISTORY

WHAT'S YOUR DIET LIKE?

Symptoms Checklist

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