test form – Counselomix

Personal Information

Please provide your date of birth

Please provide your gender

Please provide your phone number

What is your current weight (in Kg)?

What is your target weight (in Kg)?

What is your height (in meters)?

Medical Information

7. Do you suffer from any medical condition? If yes, please specify

Medical Information

Are you currently taking any medications?

If yes, please provide details of medication (name, dosage, frequency, etc)

Are you currently taking any supplements (this includes vitamins, minerals or fitness related supplements)

If yes, please specify

Exercise and Lifestyle Information

Do you exercise

How regularly do you exercise?

Exercise and Lifestyle Information

How long are your training/exercise sessions?

Have you suffered from any exercise related injury? If yes, please specify

Do you have any exercise/training restrictions? If yes, please specify

Have you attached the relevant medical reports, blood reports or genetic reports in your email response?

Personal Information

Please provide your date of birth

Please provide your gender

Please provide your phone number

What is your current weight (in Kg)?

What is your target weight (in Kg)?

What is your height (in meters)?

Medical Information

Do you suffer from any medical condition? If yes, please specify

Are you currently taking any medications?

If yes, please provide details of medication (name, dosage, frequency, etc)

Are you currently taking any supplements (this includes vitamins, minerals or fitness related supplements)

If yes, please specify

Immune Health

Have you had or do you currently have SARS viral/COVID-19 infection? If yes, how severe were the symptoms and how long did it last?

Immune Health

Do you have high blood pressure?

What is your average blood pressure reading?

Do you have diabetes?

What is your average blood sugar level or latest HbA1c?

Have you had any bone fracture or injury? If yes, please specify

Exercise and Lifestyle Information

Smoking history

Exercise and Lifestyle Information

Do you exercise

How regularly do you exercise?

How long are your training/exercise sessions?

What type of exercise do you do?

Have you attached the relevant medical reports, blood reports or genetic reports in your email response?

Personal Information

Please provide your date of birth

Please provide your gender

Please provide your phone number

Details of Partner

Please provide your partner's first name

Please provide your partner's surname

Please provide your partner's date of birth

Details of Partner

Please provide your partner's gender

Please provide your partner's phone number

Please provide your partner's Email address

Please provide your partner's postal address and country

Patient and family history

Have you, your partner, or anyone in either of your families ever had any birth defect or genetic condition not listed above? If yes, please specify.

Are you and your partner related by blood (such as cousins)?

Personal Information

Please provide your date of birth

Please provide your gender

Please provide your phone number

What is your current weight (in Kg)?

What is your target weight (in Kg)?

What is your height (in meters)?

Medical Information

Do you suffer from any medical condition? If yes, please specify

Are you currently taking any medications?

If yes, please provide details of medication (name, dosage, frequency, etc)

Are you currently taking any supplements (this includes vitamins, minerals or fitness related supplements)

If yes, please specify

Nutrition Information

What is your exercise/fitness goal?

Nutrition Information

Do you follow a specific diet plan? If yes, please specify. Example - Vegan, vegetarian, keto, paleo, etc.

Do you have any food allergies? If yes, please specify

Do you have any food intolerances? If yes, please specify

Have you followed any diets in the past that you feel may or may not have worked for you? if yes, please specify

Do you experience any food cravings? If yes, please specify

What do you typically eat for breakfast?

What do you typically eat for lunch?

What do you typically eat for dinner/supper

What do you typically snack on throughout the day?

Have you attached the relevant medical reports, blood reports or genetic reports in your email response?

Personal Information

Please provide your date of birth

Please provide your gender

Please provide your phone number

Details of Partner

Please provide your partner's first name

Please provide your partner's surname

Please provide your partner's date of birth

Please provide your partner's gender

Details of Partner

Please provide your partner's phone number

Please provide your partner's Email address

Please provide your partner's postal address and country

Patient and family history

Have you, your partner, or anyone in either of your families ever had any birth defect or genetic condition not listed above? If yes, please specify.

Are you and your partner related by blood (such as cousins)?

If yes, please specify the relation.

Have you, your partner, or anyone in either of your families had a baby who died shortly after birth or in childhood? If yes, please specify

Patient and family history

Have you, your partner, or anyone in either of your families had a stillbirth or two or more pregnancy losses? If yes, please specify

Do you or your partner have a history of infertility?

Have you or your partner ever been diagnosed with cancer, a genetic condition, or another serious medical condition?

If yes, please specify the condition and which partner

Have you or your partner had any genetic tests done?

If you are interested in doing a genetic test or have been prescribed a test, please tell us a little more about it.

Do you or your partner want to add any other information?

Have you attached the relevant medical reports, treatment notes, scans or genetic reports in your email response to [email protected]?

Personal Information

Please provide your date of birth

Please provide your gender

Please provide your phone number

Are you:

Patient and family history

Have you, your partner, or anyone in either of your families ever had any birth defect or genetic condition not listed above? If yes, please specify.

Are your parents related by blood (such as cousins)?

Personal Information

Please provide your date of birth

Please provide your gender

Please provide your phone number

Are you

Breast Cancer History

If yes, please specify the details like which family member and age of diagnosis.

Colon and Uterine Cancer History

If yes, please specify the family member and age of diagnosis.

Please specify any other cancer family history.
(Please specify the family member and age of diagnosis.)

Colon and Uterine Cancer History

Have you or any family member ever been tested for hereditary risk of cancer?

If yes, please explain.

Have you had any genetic tests done?

If you are interested in doing a genetic test or have been prescribed a test, please tell us a little more about it.

Please tell us about the reason of your appointment.

Have you attached the relevant medical reports, treatment notes, scans or genetic reports in your email response to [email protected]?

Personal Information

Please provide your date of birth

Please provide your gender

Please provide your phone number

What is your current weight (in Kg)?

What is your target weight (in Kg)?

What is your height (in meters)?

Medical Information

Do you suffer from any medical condition? If yes, please specify

Are you currently taking any medications?

If yes, please provide details of medication (name, dosage, frequency, etc)

Are you currently taking any supplements (this includes vitamins, minerals or fitness related supplements)

If yes, please specify

Skin Health

Do you spend a lot of time in direct sunlight?

Skin Health

Do you spend time tanning?

Do you use sunscreen?

Do you follow a specific skin routine?

If you have a specific skin routine, please describe your routine and the products you use?

What is your perceived skin type?

Do you struggle with skin related issues or skin allergies? If yes, please specify.

Nutrition Information

Do you struggle with hair loss?

Nutrition Information

Do you follow a specific diet plan? If yes, please specify. Example - Vegan, vegetarian, keto, paleo, etc.

Do you have any food allergies? If yes, please specify

Do you have any food intolerances? If yes, please specify

How much water do you consume per day?

Have you attached the relevant medical reports, blood reports or genetic reports in your email response?

Personal Information

Please provide your date of birth

Please provide your gender

Please provide your phone number

What is your current weight (in Kg)?

What is your target weight (in Kg)?

What is your height (in meters)?

Medical Information

Do you suffer from any medical condition? If yes, please specify

Medical Information

Are you currently taking any medications?

If yes, please provide details of medication (name, dosage, frequency, etc)

Are you currently taking any supplements (this includes vitamins, minerals or fitness related supplements)

If yes, please specify

Exercise and Lifestyle Information

Do you exercise

How regularly do you exercise?

Exercise and Lifestyle Information

How long are your training/exercise sessions?

Have you suffered from any exercise related injury? If yes, please specify

Do you have any exercise/training restrictions? If yes, please specify

Have you attached the relevant medical reports, blood reports or genetic reports in your email response?

Request a consultation

Are you interested in a counselling session for a diagnosed or suspected genetic disease in you, your children/parents/relatives (except cancer)?

Are you interested in a counselling session for cancer or risk of cancer?

Are you interested in a premarital genetic counselling session for you and your partner?

Are you interested in having a session for you and your partner to discuss fertility issues and your possible future options?

Are you pregnant and need help interpreting genetic test results or choosing the best test for you and your baby?

Personal Information

Personal Information

Medical Information

Medical Information

Exercise and Lifestyle Information

Exercise and Lifestyle Information

Personal Information

Personal Information

Medical Information

Medical Information

Immune Health

Immune Health

Exercise and Lifestyle Information

Exercise and Lifestyle Information

Personal Information

Personal Information

Details of Partner

Details of Partner

Patient and family history

Personal Information

Personal Information

Medical Information

Medical Information

Nutrition Information

Nutrition Information

Personal Information

Personal Information

Details of Partner

Details of Partner

Patient and family history

Patient and family history

Personal Information

Personal Information

Patient and family history

Personal Information

Personal Information

Breast Cancer History

Colon and Uterine Cancer History

Colon and Uterine Cancer History

Personal Information

Personal Information

Medical Information

Medical Information

Skin Health

Skin Health

Nutrition Information

Nutrition Information

Personal Information

Personal Information

Medical Information

Medical Information

Exercise and Lifestyle Information

Exercise and Lifestyle Information

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