Full Name

Email Address

Date of Birth

Blood Test Date

Which panel are you having performed?
Thyroid PanelMale Hormone PanelFemale Hormone PanelMetabolic Panel (Glucose/Insulin/Lipids)Comprehensive Panel (Multiple)

Is this your first hormone/thyroid panel, or a repeat test?
First time having this panelRepeat test (had this before)

If repeat test, what were previous findings? (if applicable)

Rate your overall energy level (1-10)

Describe your energy pattern through the day
Consistent through the dayMorning person with afternoon crashSlow to start but improve through dayVariable and unpredictable

Average hours of sleep per night
Less than 5 hours5-6 hours6-7 hours7-8 hoursMore than 8 hours

Do you wake feeling rested?
Yes, most daysSometimesRarelyNever

Fatigue despite adequate restDifficulty losing weight despite effortsUnexplained weight gainDifficulty gaining muscle despite trainingLow libido or sexual dysfunctionMood changes (anxiety, depression, irritability)Hair loss or changes in hair textureSkin changes (dry, oily, acne)Temperature dysregulation (always cold or heat intolerant)Palpitations or racing heartTremor or shakinessBrain fog or difficulty concentratingDigestive issues (bloating, constipation, diarrhoea)Water retention / feeling puffyMenstrual irregularities (females)None of the above

Any significant health events in the past 12 months?
YesNo

If yes, please describe (heart attack, surgery, diagnosis, hospitalisation, etc.)

Any history of thyroid problems? (Personal or family)
Yes - personal historyYes - family historyYes - both personal and familyNo

Have you ever been told you have metabolic syndrome, prediabetes, or diabetes?
YesNoNot sure

List ALL current medications (name, dose, frequency)

List all supplements and vitamins you take

Are you taking any supplements containing biotin?

This includes: B-complex vitamins, hair/skin/nail supplements, multivitamins, "metabolism support" supplements

YesNoNot sure - I will check my supplements

Current training frequency
0-1 sessions per week2-3 sessions per week4-5 sessions per week6+ sessions per week

Rate your current stress level (1-10)

How would you describe your recovery status?
Recovering well between sessionsSometimes feel beaten downConsistently beaten down

What are you hoping to learn from this blood work?