Health Assessment Form – Black Label

Answering the following questions will connect you with one of our in-house clinicians, who will help you create your personalized Black Label formula for a fee of $75. Please respond truthfully and as thoroughly as possible to ensure the best outcome for your plan.

First name

Last name

Your email

Date of birth

Age

Sex assigned at birth:

MaleFemale

Height

Feet

Inches

Weight

Has your weight changed significantly (gain or loss of 10%) in the past 3 months?

YesNo

If yes, how much?

with

If yes, can this change in weight be explained (weight loss plan, medication side effect, lifestyle change, etc.)?

Have you taken our DNA 360 Functional Genomics Test yet?

YesNo

If yes, what is your Kit ID or the email address you used to register your Kit?

If not, would you like to do a DNA 360 before your consult? Click here. Please note that once you return your saliva sample, it typically takes 4–6 weeks to receive your final results.

List ALL prescription medications you are currently taking or have taken in the past six (6) months. List the name, the dose you are taking, and how often you are taking this.

List ALL over-the-counter medications you are currently taking or have taken in the past six (6) months. This includes pain killers, allergy medicines, and stomach relief agents. List the name, the dose you are taking, and how often you are taking this.

List ALL supplements you are currently taking or have taken in the past six (6) months. List the name, the dose you are taking, and how often you are taking this.

List ALL allergies and sensitivities you have. Also detail your reaction. For example, “Allergic to peanuts, anaphylactic reaction. Seasonal allergies, runny nose. Allergic to sulfa drugs, unknown reaction. Sensitive to tomatoes, upset stomach”.

Do you take recreational drugs?

YesNo

Do you have any medical conditions, diagnoses, or considerations we should be aware of? Are you being currently treated for any chronic condition?

How many hours do you sleep per night?

Do you have difficulties falling asleep most days per week?

YesNo

Do you have difficulties staying asleep most days per week?

YesNo

Do you wake unrested most days per week?

YesNo

If yes to any of the previous 3 questions, do you know why? If so, please explain.

Do you take longer than average to heal from cuts and bruises?

YesNo

Do you take longer than average to heal from illness like cold or flu?

YesNo

Do insect bites particularly become swollen and inflamed?

YesNo

Do you or a family member have a history of asthma?

SelfFamilyNo

Do you have a history of eczema?

YesNo

Do you have any symptoms (e.g. Shortness of breath, headaches, brain fog) to chemicals such as cleaners, perfumes, cigarette smoke, and paints, etc.?

YesNo

Are you aware of previous or current exposures to heavy metals?

PastPresentNoneUnknown

Are you aware of previous or current exposures to moulds?

PastPresentNoneUnknown

Do you have recurrent abdominal pain, cramping and diarrhea?

YesNo

Do you or a family member have an autoimmune condition such as Crohn's, Ulcerative colitis, Lupus, Psoriasis, Thyroid disorder (with positive antibodies), etc.?

SelfFamilyNo

Select the statement you most identify with:

I am on the anxious side, tend to multitask, lose focus, and get distracted easilyI am calm, focused, and see tasks through to the endI am somewhere in the middle

Select the statement you most identify with:

Compared to others, it takes more for me to experience emotional pleasureIt is easy for me to experience pleasure and emotional highsI am somewhere in the middle

Select the statement you most identify with:

I replay negative events and often feel anxiousI am relaxed and don’t replay negative events in my head.I am somewhere in the middle

Select the statement you most identify with:

I am easily startled, irritable, and often experience a low mood.It is difficult to startle me, and I am usually seen as “happy go lucky”.I am somewhere in the middle

Does your mood and mental clarity significantly improve after exercise?

YesNo

Are you prone to seasonal mood disorders, experiencing low mood during fall/winter?

YesNo

Do you experience any of the following two or more days per week:
Anxious or ‘on-edge’ feelingsLow or saddened moodPeriods where you do not feel much (i.e., do not feel happy or sad in response to events that would make others feel happy or sad)Unexplained mood swingDifficulty concentrating, ‘cloudy’ thoughtsAddictive tendencies towards a particular thing (e.g. substance like alcohol, activity like gambling, etc.).None of the above

If you experience any of the above, did that keep you from participating in life or negatively impact your life? For example, you missed or avoided work, family events, etc.? (If you selected none of the above, simply click No)

YesNo

Have you ever been diagnosed with a psychiatric condition?

YesNo

If yes, please explain.

If you are male, please only answer the following "male" questions:

[Male] Are you and/or any of your family members experiencing male pattern baldness or are bald?

SelfFamilyNo

[Male] Do you or any of your male family members have a history of prostate health related concerns?

SelfFamilyNo

[Male] How many mornings per week do you have a morning erection?

[Male] Do you have low libido?

[Male] Do you find it difficult to build muscle mass?

[Male] Do you or any family members have a history of gynecomastia (e.g. Male breasts)?

SelfFamilyNo

If you are female, please only answer the following "female" questions:

[Female] Are you currently menstruating?

If you are menstruating:

[Female] Are your cycles regular?

[Female] If not, do you know why? Please explain.

[Female] Do you have painful periods? If so, please detail.

[Female] Do you have PMS frequently? If so, please detail.

[Female] Is there anything else about your menstruation we should know? This can include signs of and/or struggles with perimenopause.

If you are not menstruating:

[Female] Are you in menopause?

[Female] If so, do you have any lingering/unresolved symptoms? Please explain.

[Female] Is there a reason (outside of menopause) that you know of as to why you do not menstruate? Please explain.

[Female] Are you currently breast feeding?

[Female] Are you currently pregnant or have plans to become so in the next six (6) months?

[Female] Do you have low libido?

[Female] Do you have cystic acne?

[Female] Do you have excess body hair?

[Female] Have you ever had cysts in your ovaries?

[Female] Do you have a more muscular or defined body type without spending too much time at the gym?

[Female] Do you or a family member have a history of breast, uterine, or endometrial cancer?

SelfFamilyNo

[Female] Do you or any female family member have a history of uterine fibroid(s) or endometriosis?

SelfFamilyNo

Do you follow a particular diet?

If "Other", please detail.

How many bowel movements do you have per day?

How many bowel movements do you have per week?

Are your bowel movements:
Firm and formedA mushy blobLittle pellets or nuggetsCombinationChanges day to day

If your bowel movements are a "combination" of the above, or changes day to day, please explain:

Do you or your family members struggle with obesity or weight gain?

SelfFamilyNo

Are you prone to weight gain, even with exercise and good caloric control in your diet?

Do you or your family members struggle to gain/maintain a healthy weight?

SelfFamilyNo

Do you have or is there a family history of Type 2 diabetes?

SelfFamilyNo

Do you or a family member have a history of heart/cardiovascular disease?

SelfFamilyNo

Do you or any family members have a history of high cholesterol or triglycerides?

SelfFamilyNo

Do you or your family have a history of stroke?

SelfFamilyNo

Do you or family members have hypertension (high blood pressure)?

SelfFamilyNo

Do you or any family members have an increased risk of varicose veins?

SelfFamilyNo

Do you exercise at least 2 times per week?

YesNo

How would you describe your daily level of activity?
Very activeModerately activeInactiveVery inactive

Does it take a longer than expected to recover from exercise?

YesNo

Have you undergone any bariatric surgery?

YesNo

If "Yes", please explain:

Are you aware of any kidney and/or liver disease in yourself or your family?

SelfFamilyNo

If "self", please explain.

Is there anything else we should be aware about you or your health?

By checking this box, you consent to participate in our medical questionnaire and agree to our informed consent form policies. Your responses will be kept confidential and will only be used for research purposes. Your privacy is of utmost importance to us, and all data collected will be securely stored. If you have any questions or concerns regarding the survey or your participation, please feel free to contact us.