Extended Epigenetic Form

Identity, Body Measurements & Chief Concern

Mandatory section · Basic personal information · Height · Weight · BMI

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Full Name *

Email *

Age *

Height (cm) *

Weight (kg) *

BMI (auto-calculated)

—

Waist Circumference (cm)

Sex *

Male

Female

Phone *

What are your primary health goals? *

Weight management

Metabolic balance

Energy & fatigue

Sleep quality

Hormonal balance

Longevity & biological age

Cognitive performance

Skin & hair health

Gut & digestion

Drug-gene compatibility

Current Diagnoses & General Health History

Chronic conditions · Family history · Previous surgeries

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Current diagnoses *

Type 2 diabetes

Prediabetes / insulin resistance

Hypertension

Dyslipidaemia

Cardiovascular disease

Thyroid disorder

Autoimmune disease

Fatty liver (NAFLD)

Sleep apnoea

Depression / anxiety

Thrombophilia / clotting disorder

No diagnosis

Any diagnosis not listed above

Any previous surgery or significant procedure?

Yes

Surgery / procedure details (if applicable)

Family medical history

Heart disease

Type 2 diabetes

Cancer

Alzheimer's / dementia

Autoimmune disease

Thrombosis / clot

If cancer history: type and relation

Medications, Supplements & GLP-1 Use

Regular medications · Vitamins/minerals · GLP-1 / GIP · Antibiotics · NSAIDs

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Current regular medications

Please indicate which medication groups you use

StatinRosuvastatin, atorvastatin, etc.

PPI (proton pump inhibitor)Omeprazole, pantoprazole, etc.

Antidepresan / SSRISertraline, paroxetine, etc.

AntihipertansifACE inhibitor, beta-blocker, etc.

Anticoagulant / blood thinnerWarfarin, clopidogrel, etc.

Thyroid medicationLevothyroxine, etc.

Metformin / antidiabetic

ImmunosuppressantCorticosteroid, cyclosporine, etc.

No medications

GLP-1 / GIP use

Never used

Currently using

Previously used

GLP-1 details (medication name, dose, duration)

Have you used antibiotics in the past 2 years?

Once

2–3 times

More than 3

Regular NSAID use (ibuprofen, naproxen, aspirin, diclofenac)?

Occasionally

Regularly (2+/week)

Vitamin / mineral / supplement use

Yes

Supplement details (name + dose)

B12 supplement form

Not using

Oral tablet

Sublingual / injection

Have you ever had a homocysteine test?

No / unknown

Yes, normal

Yes, elevated

Metabolic & Cardiovascular Status

Blood glucose · Lipid profile · Blood pressure · Coagulation · Obesity

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Fasting blood glucose (mg/dL)

HbA1c (%)

LDL cholesterol (mg/dL)

HDL cholesterol (mg/dL)

Triglycerides (mg/dL)

Systolic blood pressure (mmHg)

Lp(a) (mg/dL) — if tested

Family history of premature cardiovascular disease

No / unknown

Yes

History of thrombosis / clot (DVT, pulmonary embolism, stroke)?

Yes, in myself

Yes, in family

Weight history

Stable

Gained weight in the past year

Lost weight in the past year

Yo-yo history

Hormonal Health

Oestrogen · Testosterone · Thyroid · SHBG · HRT

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Thyroid status

No issues

Hypothyroidism (on treatment)

Hyperthyroidism

Hashimoto's

Unknown

Menstrual status (for women)

Regular

Irregular

Perimenopause

Menopause

Male / not applicable

Hormone replacement therapy (HRT) use

Yes, oestrogen

Yes, combined

Yes, bioidentical

Oral contraceptive (birth control pill) use

No / Male

Currently using

Previously used

Energy, libido and morning erection (for men)

Normal / Female

Reduced libido

Reduced morning erection

Both reduced

Testosterone therapy (for men)

No / Female

Yes, currently

Previously used

General hormonal complaints

Hot flushes

Night sweats

Mood swings

Hair thinning / loss

Weight gain tendency

No complaints

Neurocognitive & Psychological Status

Memory · Concentration · Mood · Stress · HPA axis

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Cognitive complaints

No complaints

Increased forgetfulness

Concentration difficulty

Brain fog

Difficulty making decisions

Word-finding difficulty

Psychological status

No issues

Anxiety disorder

Depression

Panic attacks

ADHD / attention deficit

Obsessive thoughts

Psychiatric medication use

Yes, SSRI / SNRI

Yes, other antidepressant

Yes, anxiolytic

Average daily stress level *

0 — No stress 10 — Extremely high

Stress response pattern

I stay calm

Briefly affected

Hard to recover

Physical symptoms

Family history of Alzheimer's or early dementia

No / unknown

Yes, 1st degree

Yes, 2nd degree

Gut, Microbiome & Immune System

Digestive complaints · Food sensitivities · Immune system · Allergy

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Digestive complaints

No complaints

Bloating / gas

Constipation

Diarrhoea (chronic)

Reflux / heartburn

Abdominal pain

Post-meal heaviness

IBS diagnosis

Lactose tolerance

I tolerate it well

Partial intolerance

Intolerant, I avoid it

Not tested

Gluten / wheat sensitivity

No issues

Suspected sensitivity

Coeliac disease diagnosed

I follow a gluten-free diet

Probiotic / prebiotic use

Regular use

Occasional use

Do you have an autoimmune disease diagnosis?

Yes

Suspected / under investigation

Autoimmune disease type

Allergic status

Food allergy

Seasonal allergy

Asthma

Egzema / atopik dermatit

Drug allergy

Alerji yok

Sleep, Circadian Rhythm & Chronotype

Sleep quality · Chronotype · Shift work · Screen exposure

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Average sleep duration

Less than 6 hours

6–7 hours

7–8 hours

More than 8 hours

Sleep quality

Very good

Good

Fair (frequent waking)

Poor

Chronotype (your natural rhythm)

Morning typeEarly riser

IntermediateEither works

Evening typeNight owl

Snoring / sleep apnoea

None

Snoring present

Sleep apnoea diagnosed

Using CPAP

Shift / night work

In the past

Currently on shift work

Evening screen / blue light exposure (before bed)

None / very little

30–60 minutes

1–2 hours

More than 2 hours

How many long-haul flights per year (jet lag)?

Never / rarely

1–2 times

3–5 times

Frequent traveller

Detox, Environment & Lifestyle

Smoking · Alcohol · Caffeine · Occupation · Environmental toxins · Physical activity

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Smoking status

Never smoked

Ex-smoker

Current smoker

Alcohol use

None

Social (a few times/month)

1–3 days per week

Daily / regularly

Pack-years of smoking (if applicable)

Daily caffeine intake

None

1 cup

2–3 cups

4+ cups

Symptoms after caffeine

No issues

Palpitations

Increased anxiety

Insomnia

Stomach upset

Physical activity

None / sedentary

Light (1–2 days/week)

Moderate (3–4 days/week)

High (5+ days/week)

Occupational / environmental toxin exposure

Yok

Chemical exposure

Air pollution

Heavy metal risk

Pesticides / agrochemicals

Plastic / BPA exposure

Daily water intake

Less than 1 L

1–1.5 L

1.5–2.5 L

More than 2.5 L

Skin & Hair Health

Skin type · Wrinkles · Hair loss · UV exposure · Cosmetic procedures

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Skin type

Normal

Dry

Oily

Combination

Sensitive / reactive

Skin complaints

No complaints

Premature wrinkles

Sagging / loss of elasticity

Hyperpigmentation (spots)

Acne / spots

Rosacea / redness

Psoriasis

Delayed wound healing

Hair loss / thinning

None

Mild (normal level)

Noticeable loss

Advanced / recession

Hair loss pattern

None / diffuse

Frontal recession

Crown thinning

Diffuse / seasonal

Sun exposure and skin burn sensitivity

Tan easily, rarely burn

Sometimes burn, then tan

Burn often, tan little

Burn very easily, never tan

High sun exposure (2+ hours outdoors per day)

Seasonal

Frequent year-round

Skin / aesthetic procedures (past or current)

Yok

Botox / fillers

Laser treatment

Peeling / RF

PRP hair treatment

Hair transplant

Nutrition & Longevity Priorities

Dietary pattern · Restrictions · Longevity goals · Additional notes

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Dietary pattern

Mixed / standard

Mediterranean diet

Low carb / keto

Intermittent fasting

Vegetarian / vegan

Gluten-free

Dairy-free

Longevity priorities

Metabolic health

Inflammation control

Mitokondri & enerji

Hormonal optimizasyon

Cognitive protection

Healthy ageing

Cardiovascular protection

Gut microbiome

Any additional information you would like to share?

Consent & Submission

GDPR / KVKK · Informed consent · Submission

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ℹ️

Important Notice: This form is designed to collect clinical information for the preparation of your epigenetic report. The report is not a diagnostic document; all clinical decisions are made by a specialist physician. The information you provide is used solely for reporting purposes and is not shared with third parties.

Data Protection Consent (KVKK / GDPR)
I confirm that the information provided above is accurate and complete. I have read the KVKK Data Protection Notice and give my explicit consent for my personal data to be processed for epigenetic reporting purposes.

I understand that this assessment is not a medical diagnostic document, that my genetic data and health information will be used for clinical report generation, and that all final clinical decisions will be made by a specialist physician.

I declare that the information provided in this form is accurate and up to date. I acknowledge that incomplete or inaccurate information may adversely affect the interpretation of the report.

After submission, your form will be combined with your genetic raw data and laboratory results to generate your
Extend Epigenetic Report. (10 Panels · 200+ SNPs · AI-assisted analysis)

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