trifecta·health — Intake Form

General Information

Today's Date

Full Name

Date of Birth

Sex Assigned at Birth

Female Male Prefer not to say

Height

Weight

Email Address

Goals & Priorities

Top 3 Health Goals (ranked)

1

2

3

Have you had genetic testing done previously?

No Yes — From:

Family Health History

Condition	Mother	Father	Sibling	Grandparent	None / Unknown
Heart disease / early cardiac event
Stroke
Type 2 Diabetes
Cancer
Autoimmune disease
Anxiety / depression
Dementia / Alzheimer's
Osteoporosis / fracture

Longevity in family — typical lifespan of grandparents:

Allergies & Adverse Reactions

#	Substance (medication, supplement, food, environmental)	Reaction
1
2
3
4
5

Any history of unusual medication response (needing higher/lower than typical doses, severe side effects, paradoxical reactions)?

Yes No

If yes, briefly describe

Symptom Severity — Past 3–6 Months

Symptom	None	Mild	Moderate	Severe

Current Medications

#	Medication	Dosage	How Long	Reason for Use
1
2
3
4
5

Regular use of NSAIDs (Advil, Aleve, Aspirin)?

Yes No

Regular use of acid blockers (Prilosec, Nexium)?

Yes No

Regular use of hormonal contraception or HRT?

Yes No

Antibiotics taken in the past 12 months?

Yes No

Current Supplements

#	Supplement	Dosage	How Long	Reason for Use
1
2
3
4
5

Diet & Lifestyle

Sex-Specific Health

Male — Hormonal & Vitality Status

Morning energy / drive

Strong Adequate Diminished

Body composition changes (muscle loss, abdominal gain) in last 2 yrs?

Yes No

Fertility goals next 24 months?

Yes No N/A

Health History Snapshot

Science Background

Which level best describes your science background?

Beginner

I am new to biology, health science, and genetics. I understand general science concepts, but I prefer explanations that are clear and not too technical — please keep explanations simple and high level.

Advanced

I have a strong understanding of biology, health, and genetics, and I am comfortable with more detailed explanations.

Professional

I have formal training or professional experience in health care, medicine, biology, genetics, or a related field, and I am comfortable with a deep technical discussion.

Science Background

Which level best describes your science background?

Beginner

I am new to biology, health science, and genetics. I understand general science concepts, but I prefer explanations that are clear and not too technical — please keep explanations simple and high level.

Advanced

I have a strong understanding of biology, health, and genetics, and I am comfortable with more detailed explanations.

Professional

I have formal training or professional experience in health care, medicine, biology, genetics, or a related field, and I am comfortable with a deep technical discussion.

Anything Else

Anything you'd like us to know before formulating your protocol

Bowel movements/day	<1 1 2–3 3+ Irregular / alternating
Glasses of water/day	<4 4–6 6–8 >8
Caffeine intake (cups/day)	0 1–2 3–4 5+ Adverse reactions? Yes No
Hours of sleep/night	<5 5–6 7–8 >8 Insomnia? Y N Sleep aids? Y N
Exercise frequency	Rarely 1–2×/wk 3–4×/wk 5+×/wk Type: Cardio Resistance Mixed
Self-rated stress level	Low Moderate High Very High
Tobacco use	None Occasionally Daily Alcohol: None 1–3×/wk 4–6×/wk Daily
Environmental exposures of note?	Yes No (mold, heavy metals, occupational chemicals, chronic infections)

Start with your DNA.