Health & Symptom Questionnaire

About You

Basic information to set up your profile.

Full name Date of birth Sex assigned at birth Ethnicity / ancestry (helps calibrate risk scores)

European African / African American East Asian South Asian Hispanic / Latino Middle Eastern / North African Native American / Indigenous Pacific Islander Mixed / Multiple Unknown / Prefer not to say

Health History

Have you ever been diagnosed with or treated for any of the following? Check all that apply. For each, indicate if it is currently active or resolved.

Autoimmune / Inflammatory

Psoriasis Psoriatic Arthritis Rheumatoid Arthritis Lupus (SLE) Multiple Sclerosis Ankylosing Spondylitis Other autoimmune (specify below)

Cardiovascular

Heart attack Stroke High blood pressure High cholesterol Arrhythmia / irregular heartbeat Heart failure / cardiomyopathy

Gastrointestinal

Crohn's Disease Ulcerative Colitis Celiac Disease IBS GERD / acid reflux Liver disease Gallbladder issues

Neurological / Mental Health

Anxiety Depression ADHD Bipolar disorder Migraines Memory concerns / cognitive decline Parkinson's symptoms / tremor

Metabolic / Endocrine

Type 2 Diabetes Type 1 Diabetes Prediabetes Hypothyroidism Hyperthyroidism / Graves PCOS Low testosterone Menopause / hormone issues

Cancer

Cancer (specify type and year below)

Pulmonary

Asthma COPD Sleep apnea Pulmonary fibrosis

Hematology / Coagulation

Blood clots (DVT / PE) Easy bruising / bleeding Diagnosed clotting disorder Anemia

Bone / Musculoskeletal

Osteoporosis / osteopenia Fractures (specify below) Joint replacement

Skin / Barrier

Eczema / atopic dermatitis Wound healing issues Keloid scarring

Surgeries (list with approximate dates) Other diagnoses or details not listed above

Current Health Status

How are you doing right now?

Overall health rating Current symptoms or concerns (what prompted this analysis?) Current medications (type to search, add dose)

Current supplements Any recent changes in health? (past 6 months)

Symptom Detail

Based on your health history, please provide more detail on the following areas.

No condition-specific questions based on your history. Click Next to continue.

Autoimmune / Inflammatory Detail

Joint involvement (check all)

Fingers / toes Wrists / ankles Knees / hips Spine / lower back Symmetric (both sides) Asymmetric (one side worse) Morning stiffness >30 min No joint involvement

Skin involvement (check all)

Plaques Nail changes Scalp Skin folds

Flare frequency Flare severity

Mild5Debilitating

Cardiovascular Detail

Chest pain / pressure Palpitations Exercise intolerance Shortness of breath Dizziness / fainting Leg swelling

Age at first cardiac event (if applicable)

Gastrointestinal Detail

Bloating / gas Abdominal pain Diarrhea Constipation Blood in stool Nausea

Food intolerances (confirmed or suspected) Currently on special diet for GI?

Neurological / Mental Health Detail

Current mood (past month)

Low5Excellent

Focus / concentration

Poor5Sharp

Psychiatric medications tried (past and present, and whether they helped)

Memory / Neurodegeneration

When did you first notice changes?

Word-finding difficulty Getting lost in familiar places Coordination changes Tremor

Metabolic / Endocrine Detail

Unexplained weight gain Unexplained weight loss Chronic fatigue Cold intolerance Heat intolerance Hair loss / thinning

Blood sugar management Thyroid medication history Hormone therapy (if applicable)

Cancer Detail

Cancer type Year diagnosed Stage at diagnosis Treatment received Current status

Pulmonary Detail

Shortness of breath on exertion Shortness of breath at rest Wheezing Chronic cough Use CPAP / BiPAP

Current pulmonary treatment

Hematology / Coagulation Detail

Easy bruising Prolonged bleeding from cuts Excessive bleeding during surgery Frequent nosebleeds

Blood thinner use

Bone / Musculoskeletal Detail

Fracture history (location, age, cause) Bone density testing

Skin / Barrier Detail

Eczema onset

Slow wound healing Keloid scarring tendency Chronic itching Chemical / product sensitivity

Triggers & Patterns (applies across all conditions)

Things that make your symptoms worse (check all)

Stress / emotional Poor sleep Alcohol Dairy Wheat / gluten Sugar / processed food Weather / season changes Illness / infection Hormonal cycle Physical overexertion Specific foods (list below) Unknown / unpredictable No clear triggers

Daily Life

Lifestyle factors that interact with your genetic predispositions.

Diet pattern Alcohol Caffeine Caffeine timing Sleep (hours per night) Sleep issues (check all)

Difficulty falling asleep Difficulty staying asleep Wake unrested Sleep is good

Exercise Stress level (past month)

Low5Severe

Sun exposure Smoking history

Family History

Has anyone in your immediate family (parents, siblings, grandparents, children) been diagnosed with:

Heart disease / heart attack (who: ) Stroke (who: ) Diabetes (who: ) Cancer (who/type: ) Autoimmune (who/type: ) Alzheimer's / dementia (who: ) Blood clotting disorder (who: ) Sudden cardiac death before 50 (who: ) Mental health conditions (who: ) Thyroid disease (who: )

Other conditions that run in your family

Your Goals

Help us focus your analysis on what matters most to you.

Primary health concerns right now What are you hoping to learn? (check all)

Understand medication responses (pharmacogenomics) Identify disease risks to monitor Understand my autoimmune condition Supplement / nutrition guidance Fitness / performance optimization Family planning / hereditary risk Insurance / prior authorization support General curiosity

Anything else we should know?

Questionnaire Submitted

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This is not a medical intake form and does not establish a patient-provider relationship.