Symptoms Questionnaire

Before you embark on your journey with GCB please fill in this questionnaire. It allows us to make sure you are reaching the correct department or purchasing the correct test or service

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:

020 7692 8377

    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)

    Would you like to receive exclusive offers and information by email? We will never sell, share or spam your email address.
    YesNo

    Please confirm that you have read and understood the GC Biosciences Disclaimer Yes

    Please prove you are human by selecting the Key.