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Home
About
What We Do
The IRIS Platform
Why Choose Iris?
Who We Help
News and Media
Investor Relations
Partner
How It Works
Process
What We Provide
Make Choices
Products & Services
People We Have Helped
What We Provide
Customized Corporate Platform and Programs
In-depth Metabolite and Functional Microbiome Tests
DNA Testing
Lifelong Clinical Studies
Product Comparison
Order
FAQ
Frequently Asked Questions (FAQ)
Contact
Blog
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Initial Questionnaire
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Initial Questionnaire
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Personal Information
First Name
Middle Name
Last Name
Date of Birth
Gender
--- Select ---
Male
Female
Other
Weight (lbs)
Personal Information
Ethnic Background
Check all that apply
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White (Europe, Middle East, North Africa)
Other
Other - Please Specify
Marital Status
--- Select ---
Single
Married
Divorced or Separated
Widowed
Highest Level of Education
--- Select ---
Elementary
High School or Equivalent
College
Postgraduate
Professional
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Current Wellness (Self Assessment)
Physical
Fitness, Diet, Excercise
Poor
Neutral
Good
Excellent
Emotional
Mood, Stress
Poor
Neutral
Good
Excellent
Mental
Memory, Processing
Poor
Neutral
Good
Excellent
Social
Family, Friends, Work, Religion, Social Media
Poor
Neutral
Good
Excellent
Living Environment
Air, Water, Ground Quality, etc.
Poor
Neutral
Good
Excellent
Current Health Issue(s) and/or Concern(s)
Heart Disease
Not Concerned
Concerned
Currently an Issue
Currently Managed
Lung Cancer
Not Concerned
Concerned
Currently an Issue
Currently Managed
Breast Cancer
Not Concerned
Concerned
Currently an Issue
Currently Managed
Colorectal Cancer
Not Concerned
Concerned
Currently an Issue
Currently Managed
CurreProstate Cancer
Not Concerned
Concerned
Currently an Issue
Currently Managed
Pancreatic Cancer
Not Concerned
Concerned
Currently an Issue
Currently Managed
Chronic lower respiratory diseases (COPD, etc.)
Not Concerned
Concerned
Currently an Issue
Currently Managed
Stroke
Not Concerned
Concerned
Currently an Issue
Currently Managed
Alzheimer's disease
Not Concerned
Concerned
Currently an Issue
Currently Managed
Diabetes
Not Concerned
Concerned
Currently an Issue
Currently Managed
Influenza / pneumonia
Not Concerned
Concerned
Currently an Issue
Currently Managed
Kidney disease
Not Concerned
Concerned
Currently an Issue
Currently Managed
Other
Not Concerned
Concerned
Currently an Issue
Currently Managed
Other
Not Concerned
Concerned
Currently an Issue
Currently Managed
Other
Not Concerned
Concerned
Currently an Issue
Currently Managed
Are there any additional concerns that you would like to share?
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Relation to Patient
--- Select ---
Self
Family
Legal Guardian
Other
Relation To Parent
Relevant Personal Medical History - 1/4
Childhood Illness
Date
Relevant Personal Medical History 2/4
Prior Hospitalizations
Date
Relevant Personal Medical History 3/4
Blood Transfusions
Date
Relevant Personal Medical History 4/4
Physical Injuries, Trauma (medical and surgical)
Date
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Next
Relevant Family Medical History
Paternal Grandfather Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Paternal Grandmother Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Maternal Grandfather Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Maternal Grandmother Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Father Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Mother Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
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Spouse Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Brother 1 Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Brother 2 Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Brother 3 Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Sister 1 Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Sister 2 Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Sister 3 Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Child 1 Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Child 2 Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Child 3 Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
Child 4 Name
Age
Disease
Status
--- Select ---
Predisposed
Diagnosed
Treatment
Remission
Recurrence
Deceased
At Age
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