DNA Testing Intake Health Questionnaire
Your information will be reviewed by a certified health professional to check for any contraindications and provide appropriate and safe recommendations, if necessary.
General Information
Patient Gender
*
Patient Gender
Male
Female
Identify as non-binary
Patient Name
*
First Name
Last Name
Patient Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Birth Date
Patient Height (in inches)
*
Patient Weight (in lbs)
*
Patient E-Mail
*
example@example.com
Reason for seeking genetic information:
*
ex: Nutrition recommendations, lifestyle recommendations, Exercise recommendations, supplement recommendations
Medical History
Please list if you have any drug allergies
ex: Penicilin
Have you ever had (Please check all that apply)
Anemia
Asthma
Cancer
Diabetes
Epilepsy Seizures
Gallstones
Heart Disease
Heart Attack
High Blood Pressure
Ulcer Disease
Hepatitis
Sleep Apnea
Thyroid Problems
Tuberculosis
Please list if you have other illnesses:
Please list any operations and dates of each:
Please list your current medications and supplements:
Healthy & Unhealthy Habits
Exercise (days per week)
Never
1-2 days
3-4 days
5+ days
Eating following a diet
I have a loose diet
I have a strict diet
I don't have a diet plan
80% strict diet, 20% loose diet
Alcohol Consumption
I don't drink
0-2 glasses/day
3-4 glasses/day
5+ glasses/day
Caffeine Consumption
I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
Do you smoke?
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Include other comments regarding your Medical History
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