Lab Data Submission

Lab Analysis Intake Questionnaire

To protect your privacy and avoid transmission of Personal Health Information (PHI), we use anonymous code names to track your lab results. This is a HIPAA-conscious process designed for secure data handling.

Step One: Generate Your Code Name

First Name:

Last Name:

Phone Number:

Date of Birth (MM-DD-YYYY):

Your code name will appear here.

Code Name (Copied from above)

Age

Sex

Male
Female
Other

Are you currently premenopausal, perimenopausal, or postmenopausal? (Females only)

Premenopausal
Perimenopausal
Postmenopausal
Not sure / prefer not to say
Not Applicable

What is your race/ethnicity? (Select all that apply)

White
Black or African American
Hispanic or Latino
Asian
Native American or Pacific Islander
Other

What is your height in feet?

Inches?

What is your weight? (lbs)

What is your waist circumference?

Under 35 inches (men) / Under 31 inches (women)
35–40 inches (men) / 31–35 inches (women)
Over 40 inches (men) / Over 35 inches (women)
I don’t know

What was your most recent blood pressure reading (Systolic / Diastolic)

What is your resting heart rate?

Under 60 bpm
60–69 bpm
70–79 bpm
80–89 bpm
90+ bpm
I don’t know

Have you been diagnosed with any of the following? (Check all that apply)

High blood pressure
High cholesterol
Type 2 diabetes
Pre-diabetes
Insulin resistance
Cardiovascular disease (heart attack, stroke)
Metabolic syndrome
Non-alcoholic fatty liver disease (NAFLD)
PCOS (if female)
Thyroid disorder (hypothyroidism, Hashimoto’s, etc.)
Autoimmune disease
Inflammatory Bowel Disease (Crohn’s or Ulcerative Colitis)
Sleep Apnea
Chronic fatigue syndrome
Chronic kidney disease
History of cancer
None of the above

Is there anything else you’ve been diagnosed with that you think we should know? (Optional: Include diagnosis, year diagnosed, and if it’s currently active.)

Do you have a family history of any of the following? (First-degree relatives only)

Type 2 diabetes
Cardiovascular disease (heart attack or stroke)
Obesity
Hypertension
Early heart disease (before age 55 in men, 65 in women)
None of the above

Do you currently take any prescription medications?

Are you currently taking or have you been prescribed any of the following? (Check all that apply)

Statins (e.g., atorvastatin, rosuvastatin)
Blood pressure medications (e.g., ACE inhibitors, ARBs, beta blockers)
Metformin
GLP-1 agonists (Ozempic, Wegovy, Mounjaro, etc.)
Hormone therapy (testosterone, estrogen, progesterone)
Thyroid medication (e.g., levothyroxine, Armour)
Antidepressants or antipsychotics
Steroids (oral or injectable, e.g., prednisone, dexamethasone)
None of the above
I prefer not to list my medications

Other prescription medications you believe we should know about (optional)

Do you currently take any vitamins or supplements?

Are you currently taking any of the following supplements? (Check all that apply)

Omega-3 / Fish Oil
Vitamin D
Magnesium
B-complex or Methylated B12/Folate
CoQ10
Red Yeast Rice
Berberine or glucose support formulas
Niacin (nicotinic acid)
NAC or Glutathione
Probiotics
Adaptogens (Ashwagandha, Rhodiola, etc.)
Fiber supplements (e.g., psyllium, prebiotics)
None of the above
I prefer not to list my supplements

I’m taking other supplements that may be relevant (optional)

How would you rate the overall quality of your daily diet? (1 = very poor, 10 = excellent and consistent)

Selected Value: 1

Do you follow any dietary pattern?

Standard American diet
Whole-food, balanced diet
Mediterranean diet
Low-carb/keto/paleo
Vegetarian/Vegan
Other

Do you avoid any of the following foods? (Check all that apply)

Dairy
Gluten
Soy
Eggs
Nuts
Red meat
Nightshade vegetables
None of the above

Do you regularly fast or practice time-restricted eating?

I do not fast or restrict eating times
I occasionally skip breakfast or delay eating (not structured)
I follow a daily time-restricted eating window (e.g., 8-hour eating window)
I intentionally fast for 16+ hours on some days
I do 24+ hour fasts occasionally or regularly
I follow a religious or cultural fasting schedule (e.g., Ramadan)
Other

Which protein sources do you consume regularly? (Check all that apply)

Chicken or turkey
Beef
Pork
Eggs
Fish (e.g., salmon, cod, tilapia)
Shellfish (e.g., shrimp, scallops)
Greek yogurt or cottage cheese
Cheese (non-cottage)
Deli meats or processed meats (e.g., bacon, sausage, lunch meats)
Tofu or tempeh
Chickpeas or beans (e.g., hummus, black beans, lentils)
Edamame
Protein powder (whey, plant-based, etc.)
Nuts or nut butters
Seeds (e.g., chia, hemp, pumpkin)
Protein bars
Bone broth

How often do you eat red meat (beef, lamb, pork)?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

Which vegetables do you consume regularly? (Check all that apply)

Spinach
Kale
Romaine or leaf lettuce
Arugula
Mixed greens or spring mix
Asparagus
Broccoli
Cauliflower
Brussels sprouts
Cabbage
Carrots
Beets
Sweet potatoes
Potatoes (white, red, gold)
Onions
Garlic
Tomatoes
Bell peppers
Cucumbers
Zucchini
Green beans
Mushrooms

How often do you eat vegetables?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

Which sources of healthy fats do you consume regularly? (Check all that apply)

Olive oil
Avocado oil
Coconut oil
Grass-fed butter or ghee
Small amounts of heavy cream or half-and-half (e.g., in coffee)
Avocados
Nuts (almonds, walnuts, pistachios, etc.)
Seeds (chia, flax, pumpkin, sunflower, etc.)
Nut butters (peanut, almond, etc.)
Salmon
Sardines
Mackerel

Which sources of unhealthy or ultra-processed fats do you consume regularly or occasionally? (Check all that apply)

Fried fast foods (fries, chicken, onion rings, etc.)
Restaurant deep-fried items
Packaged snacks (chips, crackers, cheese puffs, etc.)
Microwave popcorn (with artificial butter/oils)
Shelf-stable baked goods (packaged cookies, snack cakes, etc.)
Frozen meals or entrees (TV dinners, frozen pizza, etc.)
Cream-based dips, dressings, or sauces (ranch, Alfredo, etc.)
Margarine or hydrogenated spreads
Vegetable oils used for cooking (canola, corn, soybean, etc.)
Flavored nut butters with added sugar/oils (e.g., Nutella, flavored peanut butters)

Which whole-food carbohydrate sources do you consume regularly? (Check all that apply)

Brown rice
White rice
Quinoa
Oats
Whole wheat bread or pasta
Corn or corn tortillas
Potatoes (white, red, gold, etc.)
Sweet potatoes or yams
Winter squash (butternut, acorn, etc.)
Lentils
Chickpeas (garbanzo beans)
Black beans
Kidney beans
Peas

How often do you eat whole-food carbohydrates?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

Which fruits do you consume regularly? (Check all that apply)

Apples
Berries
Bananas
Citrus fruits (oranges, grapefruit, limes, etc.)
Pineapple
Grapes
Dried fruit (raisins, dates, cranberries, etc.)
Fruit juice (100% juice, including orange, pineapple, lime, etc.)

How often do you eat fruit?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

Which refined or processed carbohydrates do you consume regularly? (Check all that apply)

White bread or rolls
Regular pasta (non-whole wheat)
Crackers, pretzels, or chips
Baked goods (muffins, scones, croissants)
Breakfast cereals (e.g., Cheerios, Chex, Corn Flakes)
Granola bars or protein bars with added sugar
Instant oatmeal or flavored packets
Frozen waffles, pancakes, or toaster pastries
White flour tortillas
Fast food breads or buns
Snack bars or meal replacement bars

How often do you eat fast food or processed carbohydrates?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

Which of the following sugary or highly processed foods do you consume regularly? (Check all that apply)

Regular soda (Coke, Pepsi, etc.)
Diet soda or artificially sweetened drinks
Fruit juice (even 100% juice)
Sports drinks (Gatorade, BodyArmor, etc.)
Energy drinks (Red Bull, Monster, etc.)
Coffee drinks with added sugar (Frappuccino, flavored lattes, etc.)
Candy or chocolate
Ice cream or frozen desserts
Baked goods (cookies, cakes, pastries, donuts)
Sugary cereals (e.g., Frosted Flakes, Cinnamon Toast Crunch, Lucky Charms)
Fast food milkshakes / desserts
Flavored yogurts
Sweetened nut butters or spreads (Nutella, etc.)

How often do you consume sugary or highly processed foods?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

Do you typically snack between meals or after dinner?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

How often do you drink coffee or caffeinated beverages?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

How much water do you typically drink per day?

Less than 2 cups (under 16 oz)
2–3 cups (16–24 oz)
4–5 cups (32–40 oz)
6–7 cups (48–56 oz)
8–9 cups (64–72 oz)
10+ cups (80+ oz)

Have you intentionally lost weight in the last 12 months?

Which best describes you?

I would be happiest maintaining my current weight
I would be happiest losing 5–10 pounds
I would be happiest losing 15+ pounds
I would be happiest gaining weight/muscle

How would you describe your typical daily activity level?

Mostly sedentary (e.g., desk job, limited movement throughout day)
Lightly active (e.g., standing often, walking occasionally at work)
Moderately active (e.g., walking regularly, light physical duties)
Physically active (e.g., manual labor, caregiving, on feet most of the day)
Highly active (e.g., construction, farming, physically demanding work)

Rate your current activity level overall (1 = very low, 10 = very high)

Selected Value: 1

Zone 2 cardio activities you enjoy or would be open to trying: (Check all that apply — optional)

Outdoor walking (flat or hilly)
Treadmill walking
Incline treadmill hiking
Hiking outdoors (trail or elevation)
Jogging or slow running
Stationary cycling
Outdoor biking
Swimming (easy pace)
Rowing machine (moderate effort)
Elliptical or cross-trainer
Dance (light-moderate intensity: Zumba, aerobic)
Long-distance skating or rollerblading
Rucking (walking with weighted pack)
Recreational sports (tennis, pickleball, soccer, etc.)

Zone 2 cardio activities you do not enjoy or would prefer to avoid: (Check any that apply — optional)

Outdoor walking (flat or hilly)
Treadmill walking
Incline treadmill hiking
Hiking outdoors (trail or elevation)
Jogging or slow running
Stationary cycling
Outdoor biking
Swimming (easy pace)
Rowing machine (moderate effort)
Elliptical or cross-trainer
Dance (light-moderate intensity: Zumba, aerobic)
Long-distance skating or rollerblading
Rucking (walking with weighted pack)
Recreational sports (tennis, pickleball, soccer, etc.)

How often do you engage in Zone 2 cardio activities?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

High-Intensity activities you enjoy or would be open to trying: (Check all that apply — optional)

Sprint intervals (track, treadmill, hills)
HIIT workouts (e.g., Tabata, EMOM, AMRAP)
Bootcamp-style classes (F45, Barry’s, OrangeTheory, etc.)
CrossFit or functional intensity training
Plyometrics (jump squats, box jumps, burpees)
High-intensity circuit training (minimal rest between exercises)
Spinning / indoor cycling (HIIT or sprints)
Kickboxing or martial arts-based fitness
Sports practice (basketball, soccer, hockey, etc. at game pace)
Outdoor intervals (e.g., hill sprints, sand sprints, shuttle runs)
High-effort rowing or ski erg intervals
Competitive racquet sports (tennis, squash) at high intensity

the an you

High-Intensityactivities you do not enjoy or would prefer to avoid: (Check any that apply — optional)

I am not interested in high-intensity workouts
Sprint intervals (track, treadmill, hills)
HIIT workouts (e.g., Tabata, EMOM, AMRAP)
Bootcamp-style classes (F45, Barry’s, OrangeTheory, etc.)
CrossFit or functional intensity training
Plyometrics (jump squats, box jumps, burpees)
High-intensity circuit training (minimal rest between exercises)
Spinning / indoor cycling (HIIT or sprints)
Kickboxing or martial arts-based fitness
Sports practice (basketball, soccer, hockey, etc. at game pace)
Outdoor intervals (e.g., hill sprints, sand sprints, shuttle runs)
High-effort rowing or ski erg intervals
Competitive racquet sports (tennis, squash) at high intensity

How often do you engage in high-intensity exercise or training?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

Resistance training activities you enjoy or would be open to trying: (Check all that apply — optional)

Dumbbell workouts
Barbell lifting (squat, deadlift, bench press)
Kettlebell training
Resistance bands
Bodyweight workouts (pushups, pullups, squats)
Pilates or reformer training
Group fitness classes (e.g., bootcamp, F45, Orangetheory)
Circuit training
CrossFit
Powerlifting or Olympic lifting
Functional strength (e.g., kettlebells, ropes, medicine ball)
TRX / suspension training
Machine-based strength training (gym equipment)
At-home strength workouts (video/app-based)
Personal training or coaching

Resistance training activities you do not enjoy or would prefer to avoid: (Check any that apply — optional)

Dumbbell workouts
Barbell lifting (squat, deadlift, bench press)
Kettlebell training
Resistance bands
Bodyweight workouts (pushups, pullups, squats)
Pilates or reformer training
Group fitness classes (e.g., bootcamp, F45, Orangetheory)
Circuit training
CrossFit
Powerlifting or Olympic lifting
Functional strength (e.g., kettlebells, ropes, medicine ball)
TRX / suspension training
Machine-based strength training (gym equipment)
At-home strength workouts (video/app-based)
Personal training or coaching

How often do you engage in strength/resistance training?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

How would you rate your overall sleep quality? (1 = very poor, 10 = excellent)

Selected Value: 0

How many hours do you sleep each night, on average?

Less than 4 hours
4–5 hours
5–6 hours
6–7 hours
7–8 hours
8–9 hours
9+ hours

How often do you wake up feeling rested?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

Rate your daily energy levels? (1 = very low, 10 = high and sustained)

Selected Value: 0

How often do you experience an afternoon energy crash?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

Rate your current stress level (1 = calm, 10 = extremely stressed)

Selected Value: 0

How often do you feel overwhelmed by your stress?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

How often do you consume alcoholic beverages?

Daily
5–6 times per week
3–4 times per week
1–2 times per week
Rarely
Never

When you drink alcohol, how many drinks do you typically consume?

1–2
3–4
5+
I don't drink

Nicotine Use (check all that apply):

I do not currently use nicotine products
Cigarette smoking
Vaping (nicotine)
Chewing tobacco or snuff
Occasional/social use
Former user (quit)

Rate your digestion (1 = poor, 10 = excellent)

Selected Value: 0

Do you regularly experience any of the following digestive symptoms? (Check all that apply)

Bloating
Acid reflux / heartburn
Irritable Bowel Syndrome (IBS)
Constipation
Diarrhea
None of the above

Rate your overall health (Use the slider below where 1 = very poor and 10 = excellent)

Selected Value: 1

Compared to others your age, how would you rate your overall health?

Much better
Slightly better
Average
Slightly worse
Much worse

Goals (Check all that apply)

Longevity & Disease Prevention
Weight Optimization
Sustained Energy
Mental Clarity & Focus
Blood Sugar Stability
Lower Inflammation
Heart & Cardiovascular Health
Improved Sleep
Reduced Stress
Better Digestion

By submitting this form, I consent to the use of my de-identified data for pilot research and product development related to metabolic health. Participation is voluntary, and no personal identifiers will be stored with my lab results. If you have any additional comments, concerns, or questions, please share them below

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