Age
Gender at birth
Male
Female
Weight (pounds)
Height (feet)
Height (inches)
Racial identity (select all that apply)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
Racial identity by country
Blood type
Please Select
A
B
AB
O
Don’t know
Diet
Please Select
Mainly red meat
Mainly fish and other seafood
Mainly vegetables
Vegetables only
Exercise
Please Select
Every day
3 ~ 4 times per week
1 ~ 2 times per week
Don’t exercise
Smoking
YES
NO
Alcohol consumption
Please Select
Every day
3 ~ 4 times per week
1 ~ 2 times per week
Don’t drink
Caffeine consumption
Please Select
Every day
3 ~ 4 times per week
1 ~ 2 times per week
Don't drink
Pregnant? (if female)
YES
NO
Mood swings?
YES
NO
Keep regular hours of sleep?
YES
NO
Average hours of sleep?
Current or past health issue(s) (choose all that apply)
Abdominal pain
Abnormal vaginal bleeding
Anemia
Anxiety
Arthritis
Asthma
Back pain
Cancer
Colitis, ulcerative
COPD
COVID-19
Crohn’s
Deep Vein Thrombophlebitis
Dementia
Depression
Diabetes
Diverticulitis
Dizziness
ED
GI bleed
GERD
Gout
Headaches, chronic
Heart disease
Heart murmur
Heart palpations
Hemorrhoids
Hepatitis
High blood pressure
Incontinence
Irritable bowels
Kidney stone(s)
Measles
Migraines
MRSA infection
Mumps
Osteoporosis
Polio
Guillain Barre Syndrome
Prostate disease
Rash
Rheumatic Fever
Rubella
Scarlet Fever
Seasonal allergies
Seizures
Sinusitis
Sleep disorder
Somnolence
Stroke
Tendinitis
Thyroid disorder
Tuberculosis
Ulcer
Urinary frequency
Urinary pain
Vascular disease, peripheral
Other current or past health issues (type in all that apply, separated by commas)
Current medications
Past medications
Create Your Account (optional)
If you would like to edit this form in the future and be updated on our progress, please set up an account by adding your email below (optional).
Email
example@example.com
Submit
Privacy Policy
Should be Empty: