Symptoms Questionnaire

To find out what test is best for your goals, complete the symptom questionnaire below

The information provided will be private and confidential. It will not be shared with anyone unless requested by you. Please answer the below as honestly as possible by checking the boxes that relate to your experiences or symptoms. A private phone consultation is available at no charge to discuss the below if required.

GC Biosciences have specifically formulated a short but effective questionnaire to determine the best testing methods to fit your symptoms and goals. Please complete the form with as much information and honesty as possible to ensure that our team of experts provide concise feedback to assist you in the best way possible when they review this form.

Take the guesswork out of your medical, training and lifestyle goals by filling in the questionnaire. The best part is that you get to receive a complimentary review from our team of health consultants, scientists, and nutritionists.

If at any point you want more information, or have a question about your application, please do not hesitate to contact us on:

0203 476 4507

General Information

Name

Gendermalefemale

Date of birth
`

Job role

Email address

Mobile

Address

Vital Statistics

Height (cm):

Weight (kg):

Blood Pressure:

BMI

Body Fat %

Physical Activity Level

How many times do you exercise per week?

Medical History

Heart attack, bypass, any other coronary surgery?
YesNo

Chest discomfort or heart murmurs?
YesNo

High blood pressure?
YesNo

Ankle swelling?
YesNo

Shortness of breath?
YesNo

Light headiness or fainting?
YesNo

Pulmonary disease (asthma, emphysema, bronchitis)?
YesNo

Abnormal blood markers (glucose, triglycerides, cholesterol)?
YesNo

Hospitalisation or surgery?
YesNo

Diabetes or other metabolic disorder?
YesNo

Are you pregnant?
YesNo

Any reason why you cannot diet or eat certain foods?
YesNo

Is there family history of any disease?
YesNo

Are you currently on or previously been on, any medication, if so please state?

Do you currently have any of the folowing symptoms: continuous cough for alot more than an hour, high temperature (over 38 degrees)

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YesNo

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