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The Lab Report
Start Your Intake
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Step
1
of 7
Personal Information
Full Name
*
Date of Birth
*
Gender
Male
Female
Phone Number
Email Address
*
Address
Level Lunch Are
Emergency Contact Name & Phone
Next
Health Goals
What are your top 3 health goals?
Health Goals
What are your biggest health concerns or symptoms?
Next
Medical History
Primary Care Physician
Current Diagnoses
Past Surgeries or Hospitalizations
Allergies (food, medication, environmental)
Current Medications & Supplements: | Name | Dosage | Frequency | Reason |
Next
Lifestyle & Nutrition
Typical Daily Diet
Breakfast
Lunch
Dinner
Snacks
Water Intake (oz/day)
Caffeine Intake (type & amount)
Alcohol Use
Never
Occasionally
Frequently
Tobacco Use
Never
Occasionally
Frequently
Exercise Routine (type, frequency)
Next
Stress & Sleep
Stress Level (1–10)
Main Sources of Stress
Sleep Quality
Poor
Fair
Good
Excellent
Hours of Sleep per Night
Do you wake up feeling rested?
Yes
No
Next
Family History
Please indicate if any family members have had the following:
Heart Disease
Yes
No
Diabetes
Yes
No
Cancer
Yes
No
Autoimmune Disorders
Yes
No
Mental Health Conditions
Yes
No
Next
Additional Information
Please indicate if any family members have had the following:
Is there anything else you’d like your practitioner to know?
Are you able to
Swallow Capsule Vitamins
Self-Administer Injections (or have someone to do it for you?)
Do you have a preference?
When is the last time, if ever, you’ve had labs run to identify and deficiencies? If you have within the last 3 months, are you able to share your report/findings?
Submit
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Start Your Intake
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