Lab Data Submission

Lifestyle Intake Form

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

How would you rate your overall energy throughout the day? (1= very low, 10 = very high)

Selected Value: 1

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

Selected Value: 1

How stressed do you feel on an average day? (1 = very low stress, 10 = extremely stress)

Selected Value: 1

How would you rate your physical comfort overall, considering pain, soreness and physical tension? (1 = no pain, 10 = severe pain)

Selected Value: 1

How mentally clear and focused do you feel on a daily basis? (1 = very foggy, 10 = very clear)

Selected Value: 1

How would you rate your overall mood and emotional well-being? (1 = very low, 10 = very high)

Selected Value: 1

How connected do you feel to friends, family, or a support network? (1 = very isolated, 10 = deeply connected)

Selected Value: 1

How active have you been over the past week or two in terms of intentional movement or exercise? (1 = none, 10 = very active)

Selected Value: 1

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

Selected Value: 1

How would you rate your digestion overall-- including regular bloating, and comfort? (1 = very poor, 10 = excellent)

Selected Value: 1

Do you eat ultra-processed foods (frozen meals, packaged snacks, fast food, flavored bars) more than twice per week?

Do you eat vegetables at least once per day, excluding potatoes or corn?

Do you consume sweetened beverages (soda, juice, sweetened coffee/energy drinks) ≥ 3 times per week?

Do you include high-quality protein (meat, fish, eggs, legumes, protein powder) with most meals?

Do you eat past 9 p.m. more than 3 nights per week?

Do you eat red meat (beef, pork, lamb) more than 5 times per week?

Do you consume deep-fried or fast-food items at least once per week?

Do you snack between meals or after dinner more than 4 times per week?

Do you engage in steady, moderate-intensity cardio (like walking, cycling, or swimming) at least twice per week?

Do you perform resistance or strength training (using weights, bodyweight, or machines) at least twice per week?

Do you include short bursts of high-intensity movement (such as sprints, HIIT, or fast-paced sport) at least once per week?

Do you move your body for at least 30 minutes total per day, even if broken into shorter sessions?

Do you go more than 2 hours at a time during the day without standing, stretching, or moving?

Do you spend more than 8 hours per day sitting, including work, driving, or screen time?

Do you include mobility or recovery practices (like stretching, yoga, or foam rolling) at least once per week?

Do you feel physically stiff, sore, or fatigued most mornings before the day begins?

Do you usually get 7 – 9 hours of sleep per night?

Do you struggle to fall asleep, taking > 30 minutes most nights?

Do you wake up feeling mentally clear and physically restored ≥ 4 days per week?

Do you often wake during the night and stay awake 20+ minutes?

Do you keep a consistent bedtime and wake time, even on weekends?

Do you use screens, eat large meals, or consume caffeine within 1 hour of bedtime?

Do you get natural sunlight within 1 hour of waking at least 4 days per week?

Do you rely heavily on an alarm or feel groggy when waking most mornings?

Do you often feel mentally foggy, scattered, or unable to focus for extended periods?

Do you feel emotionally steady and in control of your reactions, even under pressure?

Do you regularly feel overwhelmed by responsibilities, tasks, or decisions?

Do you generally bounce back from stress within a day or two, without lingering emotional fatigue?

Do you feel disconnected from joy, motivation, or a sense of purpose most days?

Do you find it difficult to take action on things you care about, even when you have the time?

Do you get at least one moment of laughter, lightness, or genuine enjoyment most days?

Do you currently feel that your mental health is helping you function, rather than holding you back?

Do you have at least one person you can call when you're going through something hard— who actually listens and shows up?

that stressed do

Do you often go multiple days without meaningful conversation with someone you trust?

Do you regularly feel disconnected from any sense of community, group, or shared purpose?

Do you spend time (in person or on the phone) with friends, family, or loved ones at least once per week?

Do you often feel like you're carrying everything alone—with no backup, no team, and no shared load?

Do you participate in any group, gathering, or shared activity—even occasionally? (e.g. class, hobby, religious group, volunteer role, sports, support group)

Do you find it difficult to open up, ask for help, or be emotionally honest with anyone in your life?

Do you laugh, share joy, or feel emotionally uplifted with another person at least once or twice per week?

Do you follow any dietary pattern?

Standard American diet
Whole-food, balanced diet
Mediterranean
Low-carb / Keto / Paleo
Vegetarian or Vegan
Intermittent fasting
Other
Not sure

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

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
Beans of legumes (e.g., black beans, lentils, hummus)
Edamame
Protein powder (whey, plant-based, etc.)
Nuts or nut butters
Seeds (e.g., chia, hemp, pumpkin)
Protein bars
Bone broth

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

Leafy greens (spinach, kale, arugula, spring mix)
Cruciferous (broccoli, cauliflower, Brussels sprouts, cabbage)
Root vegetables (carrots, beets, sweet potatoes)
Alliums (onions, garlic)
Nightshades (tomatoes, bell peppers, potatoes, eggplant)
Squash (zucchini, butternut, acorn)
Other common vegetables (green beans, cucumbers, mushrooms)

Which cooking fats or oils do you use regularly? (Check all that apply)

Olive oil
Avocado oil
Grass-fed butter or ghee
Coconut oil
Canola oil
Corn oil
Soybean or vegetable oil
Margarine or hydrogenated spreads
None of the above
Choice 126

Which ulta-processed or packaged foods do you consume regularly or occasionally? (Check all that apply)

Packaged snacks (chips, crackers, granola bars)
Frozen meals or microwave entrees
Fried fast food (fries, nuggets, onion rings)
Shelf-stable baked goods (cookies, pastries, snack cakes)
Sugary cereals
Sweetened protein or snack bars
Ice cream or frozen deserts
Flavored yogurts or nut butters
Processed dips, sauces or spreads
None of the above

Which fermented or probiotic-rich foods do you consume regularly? (Check all that apply)

Yogurt
Kefir
Kimchi or sauerkraut
Kombucha
Miso or tempeh
None of the above

Which whole-food carbohydrate sources do you eat 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
Other lugumes (kidney beans, peas, etc.)

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.)
None of the above

How would you describe your overall carbohydrate and added sugar intake? (Check one)

Very low
Low
Moderate
High
Very high
Not sure

How do you typically prepare most of your meals?

I cook nearly all meals at home from scratch
I cook often, but use some packaged or semi-prepared items
I eat out or rely on pre-made food more than I cook
I rarely cook and rely mostly on takeout, restaurants or frozen meals

How physically active are you throughout a typical day (outside of workouts)?

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

Zone 2 Cardio Prefernces: Zone 2 refers to steady, moderate-intensity aerobic exercise that can be sustained for long periods. Which of the following Zone 2 cardio activities do you enjoy or would be open to trying? (Check all that apply)

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 (e.g., Zumba, low-impact aerobic)
Long-distance skating or rollerblading
Rucking (walking with weighted pack)
Recreational sports (tennis, pickleball, soccer, etc.)
None of the above

Zone 2 Cardio Dislikes: Which Zone 2 cardio activities do you prefer to avoid or do not enjoy? (Check all that apply)

Outdoor walking
Treadmill walking
Incline treadmill hiking
Hiking outdoors
Jogging or slow running
Stationary cycling
Outdoor biking
Swimming (easy pace)
Rowing machine
Elliptical or cross-trainer
Dance or aerobic class
Skating or rollerblading
Rucking
Recreational sports
None of the above

High-Intensity Activity Preferences: These activities involve short bursts of intense effort and can significantly raise heart rate. Which of the following high-intensity activities do you enjoy or would be open to trying? (Check all that apply)

Sprint intervals (track, treadmill, hills)
HIIT workouts (e.g., Tabata, EMOM, AMRAP)
Bootcamp-style classes (F45, Barry’s, OrangeTheory)
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 machine workouts (e.g., Concept2 Rower or SkiErg)
Competitive racquet sports (tennis, squash) at high intensity
None of the above

High-Intensityactivities Activities Dislikes: Which high-intensity activities do you prefer to avoid or do not enjoy? (Check all that apply)

I am not interested in high-intensity workouts
Sprint intervals
HIIT workouts
Bootcamp-style classes
CrossFit
Plyometric training
High-intensity circuits
Spinning or indoor cycling
Martial arts or kick-boxing
Competitive team sports
Outdoor interval sessions
High-effort rowing or ski machine workouts
Competitive racquet sports
None of the above

Strength and Resistance Training Preferences: Strength and resistance training can include bodyweight movements, equipment-based workouts, or structured lifting. Which of the following do you enjoy or would be open to trying? (Check all that apply)

Dumbbell workouts
Barbell lifting (squat, deadlift, bench press)
Kettlebell training
Resistance bands
Bodyweight workouts (pushups, squats, pull-ups)
Pilates or reformer sessions
Group strength classes (F45, Orangetheory, etc.)
Circuit training
CrossFit
Olympic or powerlifting
Functional strength (medicine balls, ropes, etc.)
TRX or suspension training
Machine-based strength (gym equipment)
At-home strength workouts (video/app-based)
Personal training or coaching
None of the above

Strength & Resistance Training Dislikes: Which strength or resistance training methods do you prefer to avoid or do not enjoy? (Check all that apply)

Dumbbell workouts
Barbell lifting
Kettlebell training
Resistance bands
Bodyweight training
Pilates or reformer work
Group strength classes
Circuit training
CrossFit
Olympic or powerlifting
Functional strength
TRX or suspension training
Machine-based gym equipment
At-home strength workouts
Personal training or coaching
None of the above

On a typical day, how many cups (8 oz) of plain water do you drink?

Fewer than 3 cups
3-5 cups
6-8 cups
More than 8 cups

Do you typically drink water within the first hour after waking?

Which of the following do you drink as often or more often than plain water? (Check all that apply)

Coffee
Tea
Soda
Energy drinks
Juice
Flavored or enhanced water (e.g., electrolyte powders, vitamin drinks)
Alcohol
Other
None of these

Do you frequently substitute meals or snacks with liquid calories (e.g., smoothies, shakes, lattes, meal replacements)?

Yes
No
Occasionally

How would you describe your typical daily coffee / caffeine intake?

None
1-2 cups, all before noon
1-2 cups, some after noon
3 or more cups, all before noon
3 or more cups, some after noon

How often do you consume alcohol?

Never or rarely
1-3 drinks / week
4-7 drinks / week
More than 7 / week

Do you currently use any nicotine products? (cigaretts, vape, gum, etc.)?

Yes, daily
Occasionally
Not anymore
Never used

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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