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Health Intake - InYourBlueprint

Personal Information

This form helps us understand your health in full before we begin your analysis. The more you share, the more precise and useful your results will be. All information is stored securely and used solely for your personal health analysis.

First name

Last name

Date of birth

What is your email address?

Phone number

Shipping address

Biological sex

Biological sex
A
B

Height

Current weight

Occupation

Your Main Health Concern

What is the main reason you are doing this analysis? What do you most want to understand and improve about your health?

How long have you been dealing with this?

How long have you been dealing with this?
A
B
C
D
E

What have you already tried? (doctors, diets, supplements, tests, etc.)

What would a successful outcome look like for you?

Current Symptoms

Select everything that applies to you right now or regularly.

Energy & Sleep

Energy & Sleep

Digestion & Gut

Digestion & Gut

Mood & Mind

Mood & Mind

Skin, Hair & Nails

Skin, Hair & Nails

Pain & Inflammation

Pain & Inflammation

Hormones & Metabolism

Hormones & Metabolism

Immune System

Immune System

Other symptoms not listed above

Medical History

Do you have any current diagnosed conditions?

Do you have any current diagnosed conditions?

If you selected "Other" or want to add detail, describe here

Have you had any significant illnesses, infections, or diagnoses in the past that are now resolved?

Have you had any surgeries or hospitalizations?

Have you had any surgeries or hospitalizations?
A
B

Do you have a family history of any of the following?

Do you have a family history of any of the following?

Have you experienced significant trauma, chronic stress, or adverse life events that you feel have affected your health?

Have you experienced significant trauma, chronic stress, or adverse life events that you feel have affected your health?
A
B

Current Medications & Supplements

Are you currently taking any prescription medications?

Are you currently taking any prescription medications?
A
B

Are you currently taking any supplements?

Are you currently taking any supplements?
A
B

Do you have any known allergies to medications, foods, substances or any airborne allergies (pollen, cat, dog)?

Do you have any known allergies to medications, foods, substances or any airborne allergies (pollen, cat, dog)?
A
B

Lifestyle

There are no right or wrong answers here. We're not here to judge your diet — we're here to understand it. Even if you know your eating habits aren't perfect, being honest here gives us much more useful information than an idealized version.

How would you describe your diet?

How would you describe your diet?
A
B
C
D
E
F
G
H
I
J

How often do you eat home-cooked meals?

How often do you eat home-cooked meals?
A
B
C
D
E

How often do you eat fast food, takeaway, or ready meals?

How often do you eat fast food, takeaway, or ready meals?
A
B
C
D

How would you describe your typical vegetable intake?

How would you describe your typical vegetable intake?
A
B
C
D

How often do you eat sugary foods or drinks (sweets, soda, juice, pastries)?

How often do you eat sugary foods or drinks (sweets, soda, juice, pastries)?
A
B
C
D

Do you skip meals regularly?

Do you skip meals regularly?
A
B
C
D

How many times do you eat per day? Include all meals and snacks — everything.

How many times do you eat per day? Include all meals and snacks — everything.
A
B
C
D
E

Do you eat within 2 hours of going to bed?

Do you eat within 2 hours of going to bed?
A
B
C
D
E

Do you eat any of the following? Select all that apply.

Do you eat any of the following? Select all that apply.

How often do you eat a source of protein with your meals? (meat, fish, eggs, dairy, protein powder, etc)

How often do you eat a source of protein with your meals? (meat, fish, eggs, dairy, protein powder, etc)
A
B
C
D
E

What are your main protein sources? Select all that apply.

What are your main protein sources? Select all that apply.

Are there any foods you eat very often that you think might not be good for you? Or foods you know trigger symptoms?

Is there anything else about your diet or eating habits you want us to know?

How much water do you drink per day?

How much water do you drink per day?
A
B
C
D
E

How often do you drink alcohol?

How often do you drink alcohol?
A
B
C
D
E
F

Do you smoke or use tobacco/vaping products/nicotine pouches (snus)?

Do you smoke or use tobacco/vaping products/nicotine pouches (snus)?
A
B
C

How often do you exercise?

How often do you exercise?
A
B
C
D

How many hours of sleep do you get on average?

How many hours of sleep do you get on average?
A
B
C
D
E

How would you rate your sleep quality?

How would you rate your current stress level?

What are your main sources of stress? What worries you on a daily or weekly basis?

How much caffeine do you consume daily?

How much caffeine do you consume daily?
A
B
C
D

Environment & Exposures

Have you ever had a tick bite?

Have you ever had a tick bite?
A
B

Have you been exposed to mold in your home or workplace?

Have you been exposed to mold in your home or workplace?
A
B
C

Have you travelled to tropical or developing countries in the last 3-5 years?

Have you travelled to tropical or developing countries in the last 3-5 years?
A
B

Do you regularly use pesticides, herbicides, or strong chemical cleaning products?

Do you regularly use pesticides, herbicides, or strong chemical cleaning products?
A
B
C

Have you had repeated courses of antibiotics in your life?

Have you had repeated courses of antibiotics in your life?
A
B
C
D

Do you live or work near industrial areas, mold, or heavy construction?

Do you live or work near industrial areas, mold, or heavy construction?
A
B
C

Previous Testing & Medical Contact

Have you had blood tests in the last 12 months?

Have you had blood tests in the last 12 months?
A
B

Have you had any other lab tests (stool, hormones, food intolerance, hair, saliva)?

Have you had any other lab tests (stool, hormones, food intolerance, hair, saliva)?
A
B

Have you had any body scans or health analyses done at a clinic or health center?

Have you had any body scans or health analyses done at a clinic or health center?
A
B

Photo & Document Uploads

Photos and documents are completely optional but extremely useful. The more visual information you share, the more we can assess before your test kit even arrives. All uploads are stored securely and seen only by your analyst.

Tongue photo — open wide in natural light, tongue fully extended

Eye photo — close-up of both eyes, focus on the whites of the eyes

Any skin photos — eczema, rashes, acne, nail changes, or anything visible you want us to see

Any lab results or medical documents you want to share (focus on the most recent and not older then 24 months)

Final Open Questions

Is there anything else you want us to know about your health that didn't fit into the questions above?

Is there a specific area of your health you most want us to focus on?

Consent & Agreement

I consent to InYourBlueprint collecting and processing my health data, including sensitive health information and photos, for the purpose of providing personalized health analysis and consulting services.

I consent to InYourBlueprint collecting and processing my health data, including sensitive health information and photos, for the purpose of providing personalized health analysis and consulting services.

I understand that InYourBlueprint is a health analysis and consulting service, not a licensed medical practice. The analysis I receive does not constitute a medical diagnosis and does not replace the advice of a qualified doctor.

I understand that InYourBlueprint is a health analysis and consulting service, not a licensed medical practice. The analysis I receive does not constitute a medical diagnosis and does not replace the advice of a qualified doctor.

I confirm that I am 18 years of age or older.

I confirm that I am 18 years of age or older.

I have read and agree to InYourBlueprint's Privacy Policy.

I have read and agree to InYourBlueprint's Privacy Policy.