Before we start
Tell us who is answering and how we should identify you.
Answers save on this device until you send them. On a shared device, finish and send in one sitting.
Measurements
What are your current height and weight?
Use the units that are easiest for you.
What would you like help with?
What should your care team focus on first?
Choose the closest starting point, then describe it in your own words if you would like.
Tell us about a symptom, pattern, or health question. You can add more later.
Conditions and care
What diagnoses or ongoing care should we know about?
Add each current diagnosis or ongoing care item separately.
Procedures and care
What procedures, surgeries, therapy, or other care have you had?
Add one new procedure or care experience at a time.
If a procedure caused problems, record it under allergies and unwanted effects.
Do you have a condition that is better or under control?
Medicines
What medicines or other items do you use?
Choose from the list or type the full name. A name is saved once and can be used across symptoms.
Supplements
Which supplements or non-prescription items should we know about?
Your saved items appear here for review.
Your history
Have you had allergies or unwanted effects?
Record the cause and what happened if you know it.
Daily life
What everyday patterns matter to your health?
Family history
What conditions run in your family?
Diet, exposures, and files
What diet, exposure, or lifestyle context would help your care team?
What you have tried
What have you tried for a symptom or health question?
Add a medicine, supplement, food change, or other approach. Include what happened if you know.
No symptoms are saved yet.
No medicines, supplements, or other items are saved yet.
If something caused problems, record it under allergies and unwanted effects.
Blood-draw context
What should the clinic know about your blood draw and files?
Bristol stool chart reference
Use the picture or the text descriptions to choose the type that most closely matches your usual stool.
- Type 1: Separate hard lumps, like nuts.
- Type 2: Sausage-shaped but lumpy.
- Type 3: Like a sausage with cracks on the surface.
- Type 4: Like a smooth, soft sausage or snake.
- Type 5: Soft blobs with clear-cut edges.
- Type 6: Fluffy pieces with ragged edges; mushy.
- Type 7: Watery, with no solid pieces.
Your goals
What would you most like help understanding or improving?
Review and send
Review the answers you want to share.
Sending delivers them to the clinic for your care team.
This form does not provide emergency or urgent advice. If you may be in immediate danger, call emergency services now.
If you have notes from somewhere else, keep them separate here.
Your link has expired. Ask the clinic for a new link, or continue without one. Your answers here stay saved on this device.
I agree that my answers and anything I upload will be stored with my health record at this clinic, and used together with my lab results to prepare analysis for my care team.
Delivered to the clinic
Your answers were delivered to the clinic. The care team can review them with your record.
This form does not provide emergency or urgent advice. If you may be in immediate danger, call emergency services now.