PERSONALIZED HEALTH

Your SYNC Life health story

Your health is more than a list of symptoms. Tell us about your history, lifestyle, concerns and goals so our clinical team can prepare a personalized approach to your care.

Before you begin

Complete the form as thoroughly as possible. Choose “I’m not sure” when needed. Discuss medical decisions with your primary care provider.

Your answers are reviewed before your visit.
You can move backward without losing answers during this session.
Sensitive questions include “Prefer to discuss with my provider.”

ABOUT YOU

Let’s start with the essentials.

Fields marked with an asterisk are required.

Legal first name * Preferred name Last name * Date of birth * Age Mobile phone * Email * Job title Nature of work

Are you a new or returning patient? *

New patient Returning patient

Primary care provider * Preferred pharmacy * Pharmacy phone * Emergency contact name * Emergency contact phone * Relationship status * How did you hear about SYNC Life? *

Sex assigned at birth *

Female Male

YOUR HEALTH STORY

Help us understand the whole picture.

Take your time. These answers help the clinical team understand what matters most to you.

Please tell us the story behind your health. * What do you hope to achieve by working with our team? *

Goal one * Goal two Goal three

When was the last time you felt well? What has helped you feel better in the past?

Did something trigger a change in your health or symptoms?

Yes No I’m not sure

CURRENT CONCERNS

What are you experiencing now?

Add each current or recurring concern. If you have none, select the preventive-care option.

I do not have a current concern. My visit is preventive or goal-based.

Problem or symptom Onset Severity Frequency

Trend Treatment tried Response

Known triggers, diagnosis or effect on daily life

How much time have you missed from work or school in the past year because of these concerns?

MEDICAL HISTORY

Past and current conditions

Select a condition to add status, onset and treatment details.

Do you have any allergies or intolerances? *

Yes No known allergies I’m not sure

Have you had hospitalizations or surgeries?

Yes No

HORMONE AND REPRODUCTIVE HEALTH

Questions tailored to you

Answer what feels relevant or choose to discuss sensitive information privately.

Do you currently use or have you previously used hormone therapy?

Yes No Discuss privately

MEDICATIONS AND SUPPLEMENTS

What are you currently taking?

Do you take prescription or over-the-counter medications? *

Yes No

Do you take vitamins, supplements, peptides or other therapies? *

Yes No

Medication and supplement history

Please describe products, duration, reactions or side effects that may be important.

NUTRITION AND DIGESTION

Your everyday patterns

Height

Current weight Usual adult weight Desired weight (optional)

Have you had a recent unintentional weight change?

Yes No

The most important change I could make to my diet is:

Typical breakfast Typical lunch Typical dinner Typical snacks and beverages

Do you follow a special diet or nutrition program?

Fruit and vegetable servings daily Water daily Caffeine daily

Do you experience symptoms after eating?

Yes No

Digestive history (select all that apply)

Severe gastroenteritis Severe or prolonged diarrhea Food does not feel well digested Bloating after meals Reflux or heartburn Painful or excessive gas

Typical bowel-movement frequency Digestive details, triggers or stool changes

LIFESTYLE

Habits, movement and recovery

Do you currently use tobacco or nicotine?

Yes Former use Never

Do you currently drink alcohol?

Yes No

Do you currently use recreational or non-prescribed substances?

Yes No Discuss privately

Do you exercise regularly?

Yes No

Do you feel unusually fatigued or sore after exercise?

Yes No

MINDSET AND SLEEP

How are you feeling day to day?

Current vitality compared with one year ago Current stress level: 5 of 10

Whole-person health

I generally feel happy My life has meaning and purpose I am satisfied with my work I have experienced a major loss Stress reduces my quality of life

Main sources of stress, support or important context

Average hours of sleep Typical bedtime Typical wake time

Sleep concerns (select all that apply)

Trouble falling asleep Nighttime awakenings Insomnia Not rested on waking Snoring Witnessed breathing pauses Daytime sleepiness Use a sleep aid

Sleep aid, CPAP use or other sleep details

Are you currently having thoughts of harming yourself or ending your life? *

Yes No Prefer to discuss

ENVIRONMENT

Exposures and sensitivities

Which significantly affect you?

Have you lived or worked in a damp or moldy environment?

Yes No I’m not sure

Known harmful chemical exposure?

Yes No I’m not sure

Personal-care products or environmental details you want us to know

Are you experiencing any of these symptoms right now? *

Chest pain Severe difficulty breathing New weakness, facial drooping or trouble speaking Severe allergic-reaction symptoms None of these

REVIEW AND SIGN

Make sure everything looks right.

Your complete answers will be submitted. This summary highlights the main sections.

Your SYNC Life health story

Let’s start with the essentials.

Parent or legal guardian

Help us understand the whole picture.

What are you experiencing now?

Past and current conditions

Questions tailored to you

What are you currently taking?

Your everyday patterns

Habits, movement and recovery

How are you feeling day to day?

Exposures and sensitivities

Make sure everything looks right.

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