Patient Intake Form - EpiGenetics USA

PERSONAL INFORMATION

Name:

Please enter your name

Date of Birth:

Please enter your date of birth

Age:

Address:

City:

State:

Zip:

Phone:

Please enter your phone number

Email:

Please enter a valid email address

Gender:

Male Female

Please select your gender

MOTIVATION & SUPPORT

1. What are your main health concerns/goals?

2. What would you like to accomplish through your work with us?

4. What potential obstacles might prevent you from achieving your health goals?

5. Who in your life will support you in making positive health changes?

NUTRITION & EATING HABITS

1. How many meals do you eat per day?

2. How many times per week do you eat out?

3. Do you skip meals? If yes, which ones and how often?

4. Do you follow any specific diet or nutritional program?

5. List any food allergies, sensitivities, or foods you avoid:

6. How many 8oz glasses of water do you drink daily?

7. Do you consume caffeine? If yes, what forms and how much daily?

8. Do you consume alcohol? If yes, what types and how much weekly?

9. Do you smoke or use tobacco products? If yes, what types and how much?

10. Please list all supplements, herbs, and medications you currently take:

MOVEMENT & EXERCISE

1. Do you exercise regularly?

Yes No

2. If yes, describe your exercise program (activities, duration, frequency):

3. What time of day do you typically exercise?

4. Do you experience any limitations during exercise?

TOXIN & ENVIRONMENTAL EXPOSURE

1. Have you ever been exposed to toxic chemicals, solvents, sprays, pesticides, or heavy metals?

2. Do you have any known sensitivities to chemicals, perfumes, or environmental factors?

3. Do you filter your drinking water?

Yes No

4. Do you use air purifiers in your home?

Yes No

5. Do you use natural or organic personal care products?

Yes No

6. Do you use natural or organic cleaning products?

Yes No

MEDICAL & HEALTH HISTORY

1. Please list any diagnosed medical conditions:

2. Please list any surgeries or hospitalizations with approximate dates:

3. Have you ever been diagnosed with an autoimmune condition?

Yes No

4. Have you ever been diagnosed with a thyroid condition?

Yes No

5. Have you ever been diagnosed with diabetes or pre-diabetes?

Yes No

6. Do you have any known allergies?

Yes No

If yes, please list:

7. Family medical history (please note any conditions that run in your family):

LIFESTYLE & STRESS FACTORS

2. What are your primary sources of stress?

3. How many hours of sleep do you get on average?

4. Do you have trouble falling asleep or staying asleep?

Yes No

5. Do you wake feeling rested?

Yes No

6. What is your occupation?

7. How many hours do you work per week?

8. Do you enjoy your work?

Yes No Sometimes

9. What do you do for relaxation/stress management?

HEALTH OPINIONNAIRE

Please rate each statement on a scale of 1-6:
1 = Strongly Disagree
2 = Disagree
3 = Slightly Disagree
4 = Slightly Agree
5 = Agree
6 = Strongly Agree

Statement	1	2	3	4	5	6
1. I am aware that my diet affects my health.
2. I am willing to make dietary changes to improve my health.
3. I believe nutritional supplements can help improve my health.
4. I am willing to exercise regularly to improve my health.
5. I believe stress affects my health.
6. I am willing to practice stress management techniques.
7. I believe environmental toxins affect my health.
8. I am willing to reduce my exposure to environmental toxins.
9. I believe my thoughts and emotions affect my health.
10. I am willing to address emotional factors affecting my health.
11. I believe my spiritual well-being affects my health.
12. I am willing to take responsibility for my health.
13. I am willing to make lifestyle changes to improve my health.
14. I believe my health can improve with proper support.
15. I am committed to improving my health.
16. I believe I can achieve optimal health.
17. I am willing to invest time in improving my health.
18. I am willing to invest money in improving my health.

GIRTH MEASUREMENTS

Record your body measurements below. You can track measurements over time with three different date columns.

Measurement	Date 1:	Date 2:	Date 3:
Weight (lbs)
Body Fat %
Chest (inches)
Waist (inches)
Hips (inches)
Thighs (inches)
Arms (inches)

GENERAL HEALTH ASSESSMENT

Rate each aspect of your health on a scale of 1-10 (1 = Poor, 10 = Excellent)

Health Aspect	1	2	3	4	5	6	7	8	9	10
Overall Health
Energy Level
Digestive Health
Sleep Quality
Stress Management
Mental Clarity
Physical Fitness
Emotional Well-being
Immune Function
Overall Quality of Life

FREQUENCY OF PURCHASE

How often do you purchase the following items? Select the most appropriate option for each item.

Item	Daily	Weekly	Monthly	Rarely	Never
Fresh Vegetables
Fresh Fruits
Organic Foods
Whole Grains
Lean Proteins
Processed Foods
Sugary Snacks
Dietary Supplements

TOP THREE REASONS FOR VISIT

Please list your top three reasons for seeking our services at EpiGenetics USA.

Reason #1:

Reason #2:

Reason #3:

TOXIC BURDEN ASSESSMENT

Please check all that apply to your environment and lifestyle.

Environmental Factors

Live in a major city Live near industrial area Live near conventional farm Live near major highway Live near airport History of mold exposure Concerns about water quality Concerns about air quality

Home Environment

Wall-to-wall carpeting Recent home renovation Home built before 1978 (lead paint) Use conventional pesticides Use conventional cleaning products Use air fresheners/fragrances Use conventional laundry products

Personal Care

Use conventional cosmetics Use conventional deodorant Use perfume/cologne Use hair dye/treatments Regular nail salon visits Use conventional sunscreen

Diet & Lifestyle

Use plastic food containers Microwave in plastic Use non-stick cookware Use aluminum cookware Eat conventional produce Eat processed foods Eat canned foods Eat farmed fish

Occupational Exposure

Work with chemicals Work with radiation Work with heavy metals Work with dust/particulates Work with fumes/vapors

STRESS ASSESSMENT

Rate each of the following symptoms based on your typical experience:
0 = Never or rarely experience the symptom
1 = Occasionally experience, effect not significant
2 = Occasionally experience, effect is significant
3 = Frequently experience, effect is significant

Symptom	0	1	2	3
Feeling overwhelmed
Difficulty relaxing
Irritability or short temper
Racing thoughts
Feeling anxious or nervous
Trouble falling or staying asleep
Muscle tension or pain
Headaches
Digestive problems
Fatigue

THYROID FUNCTION ASSESSMENT

Rate each of the following symptoms based on your typical experience:
0 = Never or rarely experience the symptom
1 = Occasionally experience, effect not significant
2 = Occasionally experience, effect is significant
3 = Frequently experience, effect is significant

Symptom	0	1	2	3
Fatigue or exhaustion
Cold hands or feet
Weight gain or difficulty losing weight
Dry skin
Hair loss or brittle hair
Brittle nails
Constipation
Depression or low mood
Brain fog or poor concentration
Puffy face or swollen eyelids
Hoarse voice
Muscle weakness or aches
Elevated cholesterol
Irregular or heavy menstrual periods (females)
Fertility problems

MEDICAL SYMPTOMS QUESTIONNAIRE (MSQ)

Rate each of the following symptoms based on your health profile for the past 30 days:
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe

HEAD

Symptom	0	1	2	3	4
Headaches
Faintness
Dizziness
Insomnia

EYES

Symptom	0	1	2	3	4
Watery or itchy eyes
Swollen, red or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision

GENDER-SPECIFIC HEALTH

FEMALE HEALTH

Are you currently pregnant?

Yes No Unsure

Are you trying to become pregnant?

Yes No

Menstrual Information:

PMS Symptoms:

Hormone Balance Assessment

Rate each symptom based on your experience in the past 30 days (0-3 scale)

Symptom	0	1	2	3
Hot flashes
Night sweats
Vaginal dryness
Mood swings
Decreased sex drive

MALE HEALTH

Do you have any prostate concerns?

Yes No

Date of last prostate exam:

PSA result (if known):

Hormone Balance Assessment

Rate each symptom based on your experience in the past 30 days (0-3 scale)

Symptom	0	1	2	3
Decreased libido
Erectile dysfunction
Loss of muscle mass
Increased body fat
Fatigue

OTHER SYMPTOMS, CONCERNS, OR AILMENTS

Please describe any other symptoms, health concerns, or ailments not covered in this form:

What are your primary health goals?

Do you have any questions for our team?

SUBMISSION AND CONSENT

Thank you for completing the EpiGenetics USA Patient Intake Form. Please review your responses before submitting.

Thank you! Your form has been submitted successfully.

We will contact you shortly.