Health Intake - InYourBlueprint
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.
What is your email address?
*
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?
What have you already tried? (doctors, diets, supplements, tests, etc.)
What would a successful outcome look like for you?
Select everything that applies to you right now or regularly.
Hormones & Metabolism
Other symptoms not listed above
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 surgeries or hospitalizations?
Have you had any surgeries or hospitalizations?
Do you have a family history of any of the following?
Do you have a family history of any of the following?
Current Medications & Supplements
Are you currently taking any prescription medications?
*
Are you currently taking any prescription medications?
Are you currently taking any supplements?
*
Are you currently taking any supplements?
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)?
How would you describe your diet?
*
How would you describe your diet?
How would you rate your diet quality overall?
*
How much water do you drink per day?
*
How much water do you drink per day?
How often do you drink alcohol?
*
How often do you drink alcohol?
Do you smoke or use tobacco/vaping products/nicotine pouches (snus)?
*
Do you smoke or use tobacco/vaping products/nicotine pouches (snus)?
How often do you exercise?
*
How often do you exercise?
How many hours of sleep do you get on average?
*
How many hours of sleep do you get on average?
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?
Have you ever had a tick bite?
*
Have you ever had a tick bite?
Have you been exposed to mold in your home or workplace?
*
Have you been exposed to mold in your home or workplace?
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?
Do you regularly use pesticides, herbicides, or strong chemical cleaning products?
*
Do you regularly use pesticides, herbicides, or strong chemical cleaning products?
Have you had repeated courses of antibiotics in your life?
*
Have you had repeated courses of antibiotics in your life?
Do you live or work near industrial areas, mold, or heavy construction?
*
Do you live or work near industrial areas, mold, or heavy construction?
Previous Testing & Medical Contact
Have you had blood tests in the last 12 months?
*
Have you had blood tests in the last 12 months?
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)?
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?
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)
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?
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.
