HealthHistoryForm924 | Beyond

First name

Last name

Email

What are your motivators for becoming a Beyond participant?

Reverse diabetes

Reverse chronic disease

Reduce inflammation

Reduce/eliminate medications

Weight loss

Reduce pain

Become healthier/feel better

Make everyday activities and exercise easier

Increase energy

Reduce anxiety and depression

Increase mental clarity

Balance emotional well-being

Improve sleep quality

Live longer

Medical History

Please check all the health conditions that your doctor has diagnosed.

Gastrointestinal

Cardiovascular

Neurological/Brain

Urinary/Reproductive

Musculoskeletal/Pain

Osteoarthritis

Chronic pain

Migraines

Other

Dermatological

Eczema

Psoriasis

Acne

Other

Inflammatory/Autoimmune

Metabolic/Endocrine

Please list all prescriptions and over-th-counter medications you are taking

Have any of your close relatives, parents, siblings, children, or grandparents been diagnosed with the following:

Do you have allergies?

Yes

No

Health Questions

Have you ever asked your physician to help you with your weight and medications?

No

Yes

Was your physician successful with reducing your weight and medications?

Yes

No

Not applicable

How many diets have you been on during your life?

0

1-2

3-4

5 or more

Do you experience any trouble sleeping?

Trouble falling asleep

Wake up during the night

Don't feel rested

No, I always sleep well

Do you engage in physical activity on a regular basis?

Yes

No

In the past year, how many days of work have you missed due to personal illness?

In general, how satisfied are you with your life (include personal and professional aspects)?

Health History Form

Medical History

Health Questions