Pre-consultation · Online

Comprehensive intake form.

Fill this out directly in your browser — no downloads, no emailing files back. Save time by being specific; the more complete your answers, the more precisely the underlying mechanisms can be mapped before we meet.

Estimated time: 20–45 minutes. Only your name, email, primary concern, and the two consent boxes are required — everything else is optional, so fill in what you can and leave the rest blank.

Section 01

Personal & contact

Section 02

Primary concern

Section 03

Medical history

Section 04

Gut & digestion

GI symptoms (check all that apply)
Section 05

Systems review

Neuro / cognitive
Immune / inflammatory
Cardio / autonomic
Hormonal / metabolic
Section 06

Medications & supplements

Section 07

Diet, sleep & lifestyle

Section 08

Labs & diagnostics

Section 09

Goals & consent

You'll receive a written confirmation. Lab PDFs and other attachments can be emailed to research@biomelogic.net afterwards.