Stinglab BVT Intensive // Health Intake FormPlease fill out this intake so that we are able to give you the best guidance and support on your BVT journey. Name * First Name Last Name Email * Phone * (###) ### #### Emergency Contact Name * Emergency Contact Phone Number * What time zone are you located in? * Name Of Your Doctor * Doctor's Phone Number * What condition(s) are you interested in addressing with BVT? * Your health history: please explain any underlying conditions you are currently or have previously dealt with. Autoimmunity: Do you have any autoimmune conditions including Hashimotos, Lupus, Fibromyalgia, Addison's disease, Cushings Syndrome, Graves Disease, Multiple Sclerosis, Sjögren syndrome, Rheumatoid arthritis, Pernicious anemia, or others? * Gut Health: Please explain your gut health. Have you dealt with SIBO, SIFO, or Candida? Do you have IBS, Chron's, Celiac or other digestive issues? Do you deal with constipation or loose stools? Do you experience digestive pain or discomfort? * Heart and Circulatory Health: Please list any heart or circulatory conditions you have, including Heart Disease, Arrhythmia, any history of stroke or heart attack, hypertension, POTS, or others? * Bone and Joint Health: Please list any bone or joint issues you have, including arthritis or rheumatoid arthritis, Fibromyalgia, Osteoporosis, Gout, chronic joint pain, or others. * Nervous System and Brain Health: Please list any brain or nervous system disorders you are dealing with, including Neuropathy, Dysautonomia, Epilepsy, Bells Palsy, Dementia, Alzheimers, or others? * Reproductive Hormone Health: Please explain your hormonal health. For women: have you dealt with PCOS, endometriosis, painful periods, fertility challenges, or other hormone issues? For men: Have you dealt with low testosterone, prostate cancer, infertility, or other hormone challenges? * Respiratory Health: Please explain any respiratory health conditions you have, including Cystic Fibrosis, Pneumonia, Asthma, any breathing issues or air hunger, or any others. * Metabolic Health: Please list any metabolic issues you deal with, including insulin resistance, blood sugar issues, diabetes, high blood pressure, or others? * Mold: Do you know if you've had mold exposure or dealt with mold related illness? How has it affected you? What have you done so far to address it? * Family health history: please explain the health of your family members. For ex: do they have diabetes, heart disease, cancer, autoimmune disease, liver or kidney issues? * Please explain the onset of your illness and when and how you got diagnosed. * Please provide a timeline of your illness and symptoms. What are currently the symptoms that affect your life on a daily basis? What treatments, medications, supplements or protocols have you tried so far? * Please list all supplements and medications you're currently taking. * Please list all treatments, detox protocols, infusions, alternative medical modalities you arecurrently using. * Thank you! Your responses have been saved.
