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Bio Hacking Luxe – Gene Therapy & Mental Wellness Intake Form
(Confidential & HIPAA-Protected Health Information). Please complete before your appointment.
Patient Information
First Name
*
Last Name
Phone Number
*
Date of Birth
Email
Age
*
Sex
*
Address:
*
Emergency Contact
Please provide a next of kin's contact to contact incase of any emergencies. Make sure the contact is active.
First Name
Last Name
*
*
Email Address
Phone Number
*
Medical History (check all that apply)
Medical History (check all that apply)
Cardiovascular disease
Diabetes
Kidney disease
Liver disease
Autoimmune disorders
Thyroid conditions
Cancer (current or past)
Neurological conditions (stroke, seizures, MS, Parkinson’s, etc.)
Epilepsy or history of epileptic seizures
ADHD / Autism / Neurodivergence
Psychiatric conditions
Substance abuse history
Respiratory conditions
Current or recent infections
Other:
Surgical & Hospitalization History
*
Current Medications & Supplements
*
Allergies
*
Allergies
No known allergies
Improve mental clarity, focus, and mood
Support for depression, anxiety, or stress resilience
ADHD / attention support
Addiction vulnerability awareness and support
Personalized nutrition & supplementation plan
Hormonal balance & metabolic health
Weight management & energy optimization
Mood support
Family health history evaluation
Other
