3X4 Genetics At-Home DNA Testing Questionnaire

DNA Testing Intake Health Questionnaire

Your information will be reviewed by a certified health professional to check for any contraindications and provide appropriate and safe recommendations, if necessary.
General Information
Patient Gender*
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Birth Date
Patient Height (in inches)*
Patient Weight (in lbs)*
Patient E-Mail*
example@example.com
Reason for seeking genetic information:*
ex: Nutrition recommendations, lifestyle recommendations, Exercise recommendations, supplement recommendations
Medical History
Please list if you have any drug allergies
ex: Penicilin
Have you ever had (Please check all that apply)

AnemiaAsthmaCancerDiabetesEpilepsy SeizuresGallstonesHeart DiseaseHeart AttackHigh Blood PressureUlcer DiseaseHepatitisSleep ApneaThyroid ProblemsTuberculosis
Please list if you have other illnesses:
Please list any operations and dates of each:
Please list your current medications and supplements:
Healthy & Unhealthy Habits
Exercise (days per week)

Never1-2 days3-4 days5+ days
Eating following a diet

I have a loose dietI have a strict dietI don't have a diet plan80% strict diet, 20% loose diet
Alcohol Consumption

I don't drink0-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
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DNA Testing Intake Health Questionnaire