Lab Data Submission Baseline Health Assessment 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): Generate Code Name Your code name will appear here. Copy to Clipboard Please enable JavaScript in your browser to complete this form.Code Name (Copied from above)AgeSexMaleFemaleOtherAre you currently premenopausal, perimenopausal, or postmenopausal? (Females only)PremenopausalPerimenopausalPostmenopausalNot sure / prefer not to sayNot ApplicableWhat is your race/ethnicity? (Select all that apply)WhiteBlack or African AmericanHispanic or LatinoAsianNative American or Pacific IslanderOtherDo you currently take any prescription medications?YesNo there you to 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)MetforminGLP-1 agonists (Ozempic, Wegovy, Mounjaro, etc.)Hormone therapy (testosterone, estrogen, progesterone)Thyroid medication (e.g., levothyroxine, Armour)Antidepressants or antipsychoticsSteroids (oral or injectable, e.g., prednisone, dexamethasone)None of the aboveI prefer not to list my medicationsPlease list any other prescription medications you are taking that may be relevant (Optional. If none, leave blank.)Do you currently take any vitamins or supplements?YesNoHow consistently do you take them?Daily or nearly every dayA few times per weekOccasionallyRarelyI just startedI don't currently take supplementsAre you currently taking any of the following supplements? (Check all that apply)MultivitaminOmega-3 / Fish OilVitamin DMagnesiumB-complex or Methylated B12/FolateCoQ10Red Yeast RiceBerberine or glucose support formulasNiacin (nicotinic acid)NAC or GlutathioneProbioticsAdaptogens (Ashwagandha, Rhodiola, etc.)Fiber supplements (e.g., psyllium, prebiotics)None of the aboveI prefer not to list my supplementsPlease list any other supplements you are taking that may be relevant (Optional. If none, leave blank.)Have you been diagnosed with any of the following? (Check all that apply)High blood pressureHigh cholesterolType 2 diabetesPre-diabetesInsulin resistanceCardiovascular disease (heart attack, stroke)Metabolic syndromeNon-alcoholic fatty liver disease (NAFLD)PCOS (if female)Thyroid disorder (hypothyroidism, Hashimoto’s, etc.)Autoimmune diseaseInflammatory Bowel Disease (Crohn’s or Ulcerative Colitis)Sleep ApneaChronic fatigue syndromeChronic kidney diseaseHistory of cancerAnxiety or depressionNone of the aboveIs 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 diabetesCardiovascular disease (heart attack or stroke)ObesityHypertensionEarly heart disease (before age 55 in men, 65 in women)None of the aboveWhat is your height in feet?4567Inches?01234567891011What is your current weight? (lbs)What is your waist circumference?30 inches or less31–33 inches34–35 inches36–39 inches40 inches or moreWhat was your most recent blood pressure reading? Systolic (top number)Diastolic (bottom number)What is your resting heart rate?Under 60 bpm60–69 bpm70–79 bpm80–89 bpm90+ bpmI don’t knowHave you intentionally lost weight in the last year?YesNoWhich best describes your current weight goals?I would be happiest maintaining my current weightI would be happiest losing 5–10 poundsI would be happiest losing 15+ poundsI would be happiest gaining weight/muscleRate 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 betterSlightly betterAverageSlightly worseMuch worseGoals (Check all that apply)Longevity & Disease PreventionWeight OptimizationSustained EnergyMental Clarity & FocusBlood Sugar StabilityLower InflammationHeart & Cardiovascular HealthImproved SleepReduced StressBetter DigestionBy 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 belowSubmit 7605 SE 27th Street, Suite 103Mercer Island, WA 98040(Call or Text) 206-317-7000