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Client Intake Form

Ensure you have filled out all your personal health and related information via my intake form, so that I can begin looking into your unique situation.

First Name

Last Name

E-mail

Phone

Mailing address

Date of birth

Age

Sex

Male (XY) Female (XX) Other (X, XXY, etc.)

Gender

Masculine (he) Feminine (she) Neuter (they)

Weight in lbs.

Height in inches

Waist circumference in cm.

Please describe what you are looking to achieve health-wise by way of my services.

Do you have a primary care doctor?

Yes No

How do you plan to get any blood testing done that you may need?

I am confident my doctor will order any testing I request I'm not confident that my doctor would order the testing I request I already have another service through which I will get my testing done I am in the U.S. and would like you to e-mail me the tests, so I can make a simple purchase and get the testing done

Have you been diagnosed with any medical conditions by a doctor?

Are you currently taking any medications? If so, which?

Are you currently taking any dietary supplements? If so, which? Please be specific by listing brand names, chemical formulations, and dosages. Or, if possible, paste links to the specific supplements on a website like Amazon or iHerb.

How many times a day do you eat?

Do you fast? If so, please describe your fasting schedule.

Which label best fits your dietary habits?

strict carnivore mostly carnivore omnivore pescatarian lacto-ovo vegetarian vegan

How often do you eat meat (red meat, white meat, seafood, eggs, etc.)?

If you eat meat, do you eat organ meat?

daily most days occasionally once a month never

Please describe what foods you typically eat, what snacks you eat, and what drinks you drink and how often you drink them.

How often do you cook at home versus go out to restaurants to eat?

What fats/oils do you cook with?

How much sleep do you typically get? Would you say it is good quality sleep?

How much sun exposure do you typically get in the summer and in the winter?

How would you rate your typical stress level?

Is your lifestyle busy, slow, very athletic, sedentary, etc.?

Please check all of the following symptoms you have experienced within the past 6 months:

HEAD and MENTAL

feeling unwell/"off" extreme fatigue/lethargy brain fog / reduced mental awareness poor concentration absent-mindedness memory loss difficulty finding words intracranial hypertension cerebral edema headache migraine tinnitus dizziness / vertigo reduced auditory acuity hearing loss loss of initiative depression anxiety panic attacks ADHD irritability / anger tantrums pseudobulbar affect pica / ice chewing

SKIN, HAIR and NAILS

hair loss cold hands/feet flushing / mild pyrexia / temperature spikes / hot flashes heat or cold intolerance excessive or no sweating easy bruising flaking of the fingertips or palms brittle nails soft or thin nails clubbed nails spoon/concave nails dry/scaly skin oily skin pale skin yellowed skin dermatitis / seborrhea / itchy skin / rash / dandruff fibrosis inflammation of the mouth/lips cracks at the corners of the mouth dark circles under the eyes delayed wound healing generalized or abdominal swelling

NERVES and MUSCLES

arthritis / bone/joint pain fibromyalgia muscle soreness muscle cramps muscle twitching generalized muscle weakness upper body muscle weakness / reduced grip strength dysarthria / poor muscular control of speech restless legs burning feet teeth clenching or grinding ataxia / abnormal gait nerve pain or sciatica increased sensitivity of the extremities pins, needles, tingling, or burning of the extremities peripheral/sensory neuropathy

EYES

tired eyes excessive tearing xerophthalmia / xerosis / dry eyes itchy/sandy eyes bloodshot eyes bitot's spots nystagmus / involuntary eye movements conjunctivitis / pink eye keratomalacia / clouding of the cornea keratoconus / thinning or bulging of the cornea vascularization of the cornea keratitis / corneal inflammation blepharitis / eyelid inflammation cataracts amblyopia / lazy eye photophobia / light sensitivity hemeralopia / poor day vision nyctalopia / poor night vision optic nerve atrophy / blurry, hazy, or double vision ocular rosacea dilated pupils darkened eye color visual disturbances loss of color vision

HEART and LUNGS

shortness of breath or difficult/labored breathing stridor / harsh/vibrating noise when breathing breath-holding spells reduced aerobic performance tachycardia arrhythmia palpitations chest/sternal pain low or variable blood pressure / POTS / syncope high blood pressure increased allergies increased asthma

DIGESTIVE

dry mouth buccal sores / sores inside the mouth sore throat throat or tongue swelling painful, stinging, or red tongue globus / lump in the throat dysphagia / difficulty swallowing upper esophageal webbing anorexia / loss of appetite nausea cyclic vomiting syndrome heartburn / gastritis diarrhea constipation defecation pain anal itching sudden, intractable weight gain sudden, intractable weight loss

REPRODUCTIVE

menorrhagia / heavy or very painful menstruation leukorrhea / excessive vaginal discharge acute vulvitis / inflammation, redness, or itching of the vulva excessively foul odor from the vagina ulceration of the foreskin dermatitis of the foreskin, scrotum, or upper thighs sexual dysfunction or dissatisfaction pain during sexual intercourse preëclampsia growth failure / failure to thrive

SLEEP

difficulty falling asleep waking up from sleep often or for no reason falling asleep involuntarily sleep apnea

MISCELLANEOUS

frequent viral infections (cold sores, ear infections, sinus infections, flu-like illnesses, etc.) inexplicable glucose fluctuations

How long have you had the symptoms you marked off?

Have you had any other issues in the past 6 months worth noting?

Have you had 23andMe or another company analyze your DNA?

How did you hear about me / Elusive Iron?

Any further comments?

Terms & Conditions

I have read the Services FAQ, and I understand that I will NOT be receiving medical advice. I understand this service is not a replacement for consulting my personal physician on specific medication, dietary, and supplement changes.

Once you submit this form, you will be sent to a page where you can upload blood test results if you have any. I will then review all your information and reply to you in the next few days. Thank you!

Upload Lab Results

If you already have labwork (blood test results, urinalysis results, CAC scan results), please upload it here.

Your name

E-mail

Upload Lab Results (PDF, JPG, or PNG)