Predict Panel Labs Onboarding Form

Predict Panel Labs Onboarding Form
Name*

First NameLast Name
Email Address*
example@example.com
Best Phone Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Birth Date*

DayMonthYear
Date
Ethnicity
Gender*
Abdominal Circumference
(Current Measure Around Waist Between Lowest Rib and Highest Hip Bone- Near Belly Button in inches)
Height
Weight
BMI
Waist to Height Ratio:
Current Performance Status (ECOG)

0 - Normal - Fully Active1 - Restriction of Strenuous but Active2 - Up and Active more than 50% of time3 - Limited Self Care and in Bed more than 50% of Day4 - Completely Disabled
How would you best describe your exercise habits?

1 - Great as I continue to get exercise as in the past through strenuous work or fitness efforts - >5 one-hour sessions per week on average2 - Good - usually 3-5 sessions per week3 - Fair - 0-2 sessions per week on average4 - I rarely exercise or do strenuous physical activity in my normal week5-Other
Functional Measure-What Describes Me Best

1 - I can walk more than a mile at a brisk pace today with ease.2 - I could probably walk a mile but with some challenges and stops today.3 - I cannot likely walk a mile but I can stand up on my own and get around the house safely today.4 - I need help standing up from a chair and basic walking today.5 - I am bedridden most of the day now.
Functional Measure- One minutes Max - How many pushups can I do in a minute? (Women from knees/ Men from toes)

1 - 10 to 202 - 21 to 303 - 31 to 404 - 41 to 505 - 51 to 606 - Over 60
Body Measurement Changes- What best Describes me now

1 - My weight and muscle mass - strength has not changed in the last 6 months2 - I have lost 5-10% of weight and muscle mass over the last 6 months3 - I have lost 11 to 20% of weight and muscle mass in the last 6 months4 - I have lost more than 21% over the last 6 months5- Other
How Would You Best Describe Your Lifelong Diet?

1 - Standard American Diet or Canadian Equivalent2 - Low Fat Good Protein-Carbohydrate Diet3 - Low Carbohydrate-Low Sugar Emphasis Diet4 - Keto or Atkins Like Diet5 - Vegetarian or Vegan Diet6 - Gluten Sensitive Diet7 - Modified keto with intermittent fasting8 - Animal Sourced of Carnivore Style Diet9 - Other
How would you best describe your diet now?

1 - Standard American Diet or Canadian Equivalent2 - Low Fat Good Protein-Carbohydrate Diet3 - Low Carbohydrate-Low Sugar Emphasis Diet4 - Keto or Atkins Like Diet5 - Vegetarian or Vegan Diet6 - Gluten Sensitive Diet7 - Modified keto with intermittent fasting8 - Animal Sourced of Carnivore Style Diet9 - Other
How would you best describe your fluid hydration strategy?

1 - I mainly drink when I am thirsty choosing flavored and fruit drinks or whatever is available.2 - I have no dedicated strategy but drink non-caloric healthy options when thirsty.3 - I understand the role of hydration in restoring fluids and electrolytes to my cells and removing toxins and have a dedicated practice to achieve that.Other
How would you describe your sleep currently?

1 - Excellent - 7-9 hours with initiation a few hours after dark2 - Fair - 5-7 hours usually with variable initiation times3 - Disrupted 4-6 hours with wake-ups due to symptoms4 - Poor - 4 hours or less Due to night shift work, chronic insomnia, other issues5- Other
I currently measure my sleep with an app of some type

1 - Yes2 - No3 - No, but would like to discuss options
How would you best describe your work life currently?

1 - Currently working full time outside the home2 - Currently working part-time-less than 25 hrs. outside the home3 - Retired Previously not for medical reasons4 - Disabled due to this Medical Diagnosis5 - Work in the home as homemaker-parent6 - Currently a student, between jobs, other
How would you best describe your social network and support?

1 - Great - frequent interaction with family, friends, and work colleagues2 - Reduced since a medical diagnosis or the pandemic, but a handful of close contacts available3 - Limited to few family members or friends4 - I feel alone or abandoned5- Other
How would you best describe your perceived level of stress?

1 - I have constant anxiety due to my current condition2 - I have stress but my coping mechanisms and supports help me some of the time3 - I feel in balance with good coping strategies4 - Other
How would you best describe your spiritual life?

1 - I participate in a formal religion currently and it is a big part of my life2 - I previously participated in a structured religion but no longer at this time3 - I am spiritual but have no formal religion or structure4 - I am an atheist or agnostic5 - I have neglected my spiritual needs and wish to increase attention in this area5- Other
I would best describe my intimate life currently

1 - I have normal active sexual relations with my partner2 - I have challenges due to my medical diagnosis3 - I have challenges due to non-cancer related issues in this area4 - I have no partner in my life at this time5 - My partner and I have no interest in an intimate sexual relationship at this time6- Other
How would you best describe your past medical history?

1 - I have no prior common medical diagnosis other than cancer2 - I have 1 other common medical diagnosis3 - I have 2-3 common medical diagnosis4 - I have more than 3 common medical diagnoses in addition to my cancer
Select all that apply to you for common medical conditions (May choose all that apply).

1 - Current cancer but also previous different non-skin cancer diagnosis2 - Cardiovascular disease (CHF, HTN, Arrhythmia -other)3 - Pulmonary disease (COPD, Emphysema, Asthma, Long covid, Pulmonary HTN, other breathing issues)4 - Brain-Central Nervous system disease (Stroke, Dementia, Parkinson’s Dz. Multiple Sclerosis other)5 - Mental Disorder (Depression, Bipolar, Schizophrenia, ADD other)6 - Liver Disease (Cirrhosis, Hepatitis, Hemochromatosis, Other)7 - Kidney disease (Chronic Renal Failure, Nephrotic syndrome, other)8 - Diabetes (Type 1, Type 2 with medication use)9 - Endocrine disease (Thyroid dysfunction, Hormone imbalance, Pituitary, or glandular disease, other)10 - Gastro-Intestinal disease (ulcer, colitis, pancreatitis, diverticulitis, other)11 - Muscular-Skeletal disease- (muscle dystrophy, osteoporosis, Graves’ Disease other)
How would you best describe your breathing status?

1 - I am a general or chronic mouth breather due to happenstance or some physical limitation such as sinus problems2 - I am aware of the importance of nostril breathing but toggle between mouth and nostril through the day, snore problems at night3 - I am dedicated and attentive to nostril breathing as default at rest and low-level exercise to enhance my oxygen delivery and relaxation responseOther
How would you best describe your digestion currently?

1- Normal for me 1-3 BM per day2- Normal for me - 1 BM every few days3- Abnormal with frequent diarrhea4- Abnormal with moderate constipation5- Abnormal with alternating constipation and diarrhea6- Other
How would you best describe your current dental health?

1 - Excellent - regular check-ups and no known cavities, necrotic teeth, gingivitis, or problems2 - Excellent with regular check-ups, and no known problems but the history of one or more root canals3 - I have currently a problem cavity or necrotic tooth and or untreated gum disease4 - I have a known bone cyst or pocket above or below a prior root canal5 - I have had my teeth extracted and have full dentures6 - I have had one or more extractions and implant placement restoration7- Other
My baseline resting blood pressure is closest to-

1 - Normal- under 130/80 or so2 - Slightly high - in the range 140/90 or so3 - Generally high - 150/100 or so4 - Generally low - 100 or less over 70 or less5- Other
How would you best describe your prescription medication use now?

1 - I take no regular prescription medications2 - I use 1-3 additional medications per day3 - I use 4-5 additional medications per day4 - I use greater than 5 additional medications per day5- Other
How would you best describe your non-prescription or OTC medication (Ex. Aspirin, Advil) use per day?

1 - I take no regular OTC medications2 - I use 1-3 additional OTC medications per day3 - I use 4-5 additional OTC medications per day4 - I use greater than 5 additional OTC medications per day5- Other
How would you best describe your supplement or vitamin (Ex. D3, Omega3) use now?

1 - I use no regular supplements of any type per day2 - I use no regular supplements other than MMC/Core5 supplement options now3 - In total, I use 1-5 regular supplements per day4 - In total, I use 6-10 regular supplements per day5 - In total, I use greater than 10 regular supplements per day6- Other
Are you allergic to any medications?

YesNo
Please describe your medication and allergic response:
List all daily medications:
List all daily supplements:
How would you best describe why you chose the MMC service?

1 - To better review my baseline health2 - A deeper inquiry will alleviate my cancer risk concerns3 - A deeper inquiry may help reduce my cancer risk in addition to other chronic disease/conditions3 - My health is deteriorating and this inquiry may identify some causes4- Other
List any additional major issues we should know:
What additional services should our virtual platform consider offering to aid people like yourself?
Heal Navigator

Yes
Consent Form
I, {name}, understand that Meakin Metabolic Care (MMC) is a virtual platform that is striving to lower the financial burden and inefficiencies of a typical medical practice to bring fellow Americans the best services to better their health.

I understand that the virtual platform does not allow for standard physical exams and other onsite procedures and inquiries that enhance findings and insights. I, therefore, understand I need to maintain a local physician and possible oncologist if appropriate to support my care.

I understand that the fees charged for these services are not covered by Medicare, Medicaid, or other insurance and MMC does not submit information for insurance approvals or referrals.

I understand that MMC strives to be efficient to lower the cost to their patients and therefore scheduling and interactions are done through the patient portal and website.

In keeping with our mission, MMC is uniquely mindful of the overwhelming nature of certain diagnoses and associated costs and has opportunities upon request to lower or eliminate fees.

I understand that metabolic management for disease prevention and cancer care enhancement is an evolving pattern of care and randomized trials for supplements and repurposed drugs used off-label are rarely available.

I understand MMC will offer customized pharmaceutical and supplement options and use laboratory values and known algorithms to optimize safety.

I understand it is my responsibility to submit the needed medical information to the portal and offer feedback at the evaluations to best enable MMC to offer safe care.

I understand that MMC is not set up to call and communicate with other physicians on a routine basis and it is the patient responsibility to review with their other physicians the care program offered by MMC and the associated medications and supplements.

I understand MMC will use best practices with lifestyle modifications applied to best tolerance to also support my course.

I understand I am not obligated to continue the care after initiation, and I proceed by my own choice.

I understand I can terminate this relationship at any time and MMC can terminate at any time as well.

I understand the challenging nature of virtual care and therefore will be understanding if electronics or Wi-Fi impact the schedule and be mindful of the time windows in the scheduling to best enable MMC to stay on track for other patients as well.

I understand the goals and purpose of MMC in the support of my health goals and am ready to proceed and consent to the evaluation and discussion of therapies using this format.
I am not domiciled in any of the following states during the time of my consultation with MMC: Alaska, Hawaii, Rhode Island, Delaware, or New Mexico*

I agree
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Predict Panel Labs Onboarding Form

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