Name
*
First Name
Last Name
Email
*
What is your age?
*
What is your height?
*
What is your weight?
*
Do you drink/consume alcohol?
*
Occasionally (1-2 drinks per week)
Regularly (3-5 drinks per week)
Heavy (6+ drinks per week)
I don't drink/consume alcohol
Do you smoke?
*
Heavy smoker (6+ cigarettes per day)
Regularly (1-3 cigarettes per day)
Occasionally (social smoking)
Never
Vapes or uses other nicotine products
Do you currently use recreational drugs?
*
No
Yes (Occasionally)
Yes (Regularly)
Do you take any OTC supplements and/or medicine?
*
(e.g., multivitamins, protein, pre-workout, etc.)
Are there any specific foods or medication you avoid or are allergic to?
*
How often do you exercise?
I don’t exercise
1-2 times per week
3-4 times per week
5+ times per week
Please provide a brief overview of your medical history
*
(e.g., surgeries, chronic illnesses, conditions).
Please provide any relevant family medical history
*
(e.g., surgeries, chronic illnesses, cancer, any other specific conditions).
How would you rate your sleep quality?
*
Excellent (I wake up rested every day)
Good (I usually wake up rested, but not always)
Poor (I often feel tired even after sleep)
How is your energy level throughout the day?
*
Stable (I feel energized all day)
Moderate (I feel tired mid-day)
Low (I feel fatigued most of the day)
Do you experience high stress or anxiety?
*
No
Occasionally
Frequently
How would you describe your sex drive?
*
High
Moderate
Low
MALES ** Do you experience any of the following?
FEMALES ** Do you experience any of the following:
Are there any symptoms you’d like to mention that weren’t covered above?
