Medical History Disclosure — Kairos Habit Lab

ID

Client Identification

Full name *

Date of birth *

Age *

Sex *

Contact number *

Program start date *

Referring lifestyle coach

A

Current Diagnosed Conditions

List all current diagnosed medical conditions. Write "None" if none. Do not leave blank.

Current diagnosed conditions *

How long have you had each condition?

Are conditions currently managed by a physician? *

Yes, all of them

Some of them

No

No diagnosed conditions

B

Medications

Include all prescription and over-the-counter medications. Include dosage and frequency.

Current medications *

Have you taken peptides, hormones, or biologics previously? *

Yes

No

If yes — which ones, dosage, and duration?

C

Surgical & Hospitalization History

Past surgeries — type and year *

Past hospitalizations — reason and year *

Any currently scheduled medical procedures?

D

Family Health History

Check all conditions that apply to immediate family — parents, siblings, grandparents.

Additional family health notes (optional)

E

Allergies

Known food allergies *

Known medication or supplement allergies *

Environmental or material allergies

Have you ever had an anaphylactic reaction? *

Yes

No

Unsure

If yes — trigger and how it was managed?

F

Lab Tests & Recent Checkups

Lab tests done in the last 6 months? *

Yes

No

Scheduled but not yet done

If yes — what tests and where?

Lab results — file name or reference

Under care of another physician? *

Yes

No

If yes — physician name, specialty, clinic

G

Smoking & Substance History

Do you smoke or use tobacco products? *

Yes, currently

Quit — less than 1 year ago

Quit — more than 1 year ago

Never

If yes/recently quit — sticks per day and years?

Do you use recreational substances or vape? *

Yes

No

Prefer not to say

If yes — what and how frequently? (confidential — for clinical safety only)

H

Client Medical Consent

Client printed full name *

Date *

Client signature *

Sign here with your mouse or finger

Medical History
Disclosure Form

Submit Medical History Form

Form submitted successfully

Medical HistoryDisclosure Form

Submit Medical History Form

Form submitted successfully

Medical History
Disclosure Form