Medical Form

Please take a minute to create your new client account below

What is your name? *

Phone *

Email *

Date of birth *

How do you prefer to be contacted? *

Email

Phone Number

If you were referred by a current patient, please let us know their full name so we can contact them to say thanks. *

Street Address *

City *

State *

Postal Code *

Marital status *

What is your marital status? *

How tall are you? *

What is your current weight? *

What is your desired weight goal? *

What is your job or profession? *

Who should we contact in case of an emergency? *

What is your emergency contact's phone number? *

Now, help us know about your medical history.

List your main health concerns by importance and also state when they started. *

List any other wellness issues you have had in the past. *

List any medical diagnosis you have received in the past such as diabetes, heart disease, depression, etc. *

List any OTC medications or supplements you take and the reasons for taking them. *

List any prescription medications you take including dosages and reasons for taking them. *

List any past surgeries, hospitalizations, accidents, serious illnesses, and injuries. *

List any known allergies to medications. *

List any known food or environmental allergies. *

Are any of your allergies life threatening? If yes, please specify. *

Has anyone in your family (parents, grandparents, siblings, children) been affected by any of the following? *

Arthritis

Cancer

AIDS/HIV

Autoimmune disorders

Hormonal imbalance

Pancreatitis

Liver failure

Blood disorders

Dementia

Parkinson's disease

Heart disease

Thyroid problems

None of the above

Add choice

When's the last time you had a blood test? *

6 months ago or less

Longer than 6 months

Let's talk about symptoms now

For the following symptoms select how often you experience them - often, sometimes, never, or 'in the past'.

General symptoms. *

Head symptoms. *

Ear, eyes, nose, and throat symptoms. *

Skin symptoms. *

Digestion symptoms. *

Mental/emotional symptoms. *

Cardiovascular symptoms. *

Respiratory symptoms. *

Neurological symptoms. *

Musculoskeletal symptoms. *

Urinary symptoms. *

Endocrine symptoms. *

Now let's talk about some gender specific symptoms. What is your gender? *

Male

Female

Female symptoms.

Contraceptive use?

Yes

No

What type of contraceptive use?

Absent periods.

Often

Sometimes

Never

Heavy bleeding or spotting between cycles.

Often

Sometimes

Never

Cervical Dysplasia/HPV.

Often

Sometimes

Never

Yeast infections.

Often

Sometimes

Never

Endometriosis

Often

Sometimes

Never

PCOS

Often

Sometimes

Never

Uterine fibroids.

Often

Sometimes

Never

Difficult menopause - hot flashes, night sweat.

Often

Sometimes

Never

Vaginal dryness.

Often

Sometime

Never

Recent changes in breasts.

Yes

No

Nipple discharge.

Yes

No

Date of last PAP exam.

Date

History or abnormal PAP exam.

Yes

No

Male symptoms.

Prostate problems.

Yes

No

Difficult urination.

Often

Sometimes

Never

Erectile dysfunction.

Often

Sometimes

Never

Let's talk about your lifestyle now.

Do you exercise? *

Yes

No

How many times a week do you exercise and what type? *

How many alcoholic drinks do you consume every week? *

Non

1 - 2

2 - 4

4+

Do you use recreational drugs? *

Yes

No

Rate your current stress level. *

1 - Lowest

2 - Low

3 - Medium

4 - High

5 - Highest

What are the primary sources of your stress? (Yes, the thoughts in your head that just popped up.) *

How times a week do you eat fast food? *

None

1 - 2

3 - 5

6+

What is the amount of soda (including diet) you drink on average per day? (Enter amount in milliliters (ml) *

How many times do you eat per day? *

How many glasses of water do you drink every day? *

1 - 3

3 - 5

6 - 8

8+

How many cups of coffee do you drink per day? *

None

1 - 2

2 - 4

4+

Are you drinking water from a source you know has minerals or using mineral drops? *

Never

Sometimes

Always

I don't know

Tell us about your health goals. *

Your health is not a guessing game. Know before you go.

NEXT

A Structured Approach to Human Optimization

Most products in this space are sold in isolation,

leaving people to figure out what works on their own

and we believe that approach falls short.

We design our protocols with intention,

combining clinically relevant compounds in a way that

aligns with how the body actually functions.

The goal is simple...

→ To create targeted, effective systems that deliver consistent

and measurable results.

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