Health & Symptom Questionnaire

Current Health Status

Tell us how you're doing right now.

Your name Date of birth Overall health rating Active symptoms or flares? Diagnosed conditions (check all)

Psoriasis Psoriatic Arthritis Rheumatoid Arthritis Inflammatory Bowel Disease Type 2 Diabetes Thyroid Disorder Cardiovascular Disease Anxiety / Depression ADHD Asthma / COPD Cancer Autoimmune (other)

Current medications (include dose if known) Current supplements

Symptoms

Joint, skin, GI, cardiovascular, neurological, metabolic, and pulmonary

Joint involvement (check all)

None Fingers / toes Wrists / ankles Knees / hips Spine / lower back Symmetric Asymmetric Morning stiffness >30 min

Skin involvement (check all)

None Psoriasis plaques Nail changes Scalp Eczema Inverse psoriasis

GI symptoms (check all)

None Bloating / gas Abdominal pain Diarrhea Constipation Acid reflux

Cardiovascular (check all)

None Palpitations Chest pain High blood pressure High cholesterol Dizziness / fainting

Neurological (check all)

None Anxiety Depression Difficulty focusing Memory concerns Migraines

Metabolic (check all)

None Unexplained weight gain Chronic fatigue Cold intolerance Blood sugar issues

Pulmonary (check all)

None Shortness of breath Wheezing Chronic cough Sleep apnea

Flares & Triggers

Patterns that help us connect your symptoms to genetic pathways

Flare frequency Known flare triggers (check all)

Stress Poor sleep Alcohol Dairy Wheat / gluten Sugar / processed foods Weather changes Illness / infection Hormonal cycle Physical overexertion Unknown

Flare severity when they occur

Mild 5 Debilitating

Mood (past month)

Low 5 Excellent

Stress level (past month)

Low 5 Severe

Lifestyle

Daily habits that interact with your genetic predispositions

Diet pattern Alcohol Caffeine Sleep (hours per night) Exercise Sun exposure

Family History & Goals

Family history (conditions and which relative) Primary health concerns right now Analysis goals (check all)

Understand medication responses Identify disease risks Understand autoimmune condition Supplement / nutrition guidance Fitness optimization Family planning Insurance / prior auth support General curiosity

Anything else we should know?

Questionnaire Submitted

Your responses have been securely delivered to your provider.
They will be integrated with your genomic analysis.

You may close this page.

This form collects health information for genomic analysis.
All data is transmitted securely and stored confidentially.
This is not a medical intake form and does not establish a patient-provider relationship.