Unlock Your Full Potential with AI-Powered Test Recommendations from Marqi Medical! Contact Information Notice: Your information is strictly confidential and only used to customize your report. We adhere to strict PHI and HIPAA guidelines. Name * First Name Last Name Email * Phone * Your data stays secure with us. (###) ### #### Age Range * (Select your group) 20–30 years 30–40 years 40–50 years 50–60 years 60–70 years 70+ years Gender * Female Male How often do you engage in physical activity (such as walking, exercise, sports, or workouts) per week? * Never 1–2 times 3–4 times 5 or more times How many alcoholic beverages do you consume per week? * <3 3-7 >7 How many hours of sleep do you typically get per night? * <6 6-8 >8 How would you rate your daily energy levels? * low moderate high How would you rate your ability to concentrate on a given task for more than 20 minutes? * low moderate high How often do you feel emotionally low, anxious, or overwhelmed? * Rarely or never Daily Occasionally (1–2 times a week) Frequently (3–5 times a week) I’m currently receiving support for mental health How often do you drink water or stay hydrated throughout the day? * I consistently drink 8+ glasses daily I drink water throughout the day, but not always 8 glasses I often forget to hydrate I mostly drink other beverages (coffee, soda, etc.) How would you describe your typical eating habits? I eat a balanced diet with whole foods most of the time I eat on-the-go or skip meals often I rely heavily on processed or fast food I follow a specific diet (e.g., keto, vegan, intermittent fasting) Other If other, please specify: Do you take any supplements, vitamins, or medications regularly? * Yes – daily Occasionally No If yes, please list down: Which of these symptoms do you experience on a weekly basis? * Brain fog Mood swings Poor sexual performance Muscle joint pains Fatigue Bloating Stomach cramps Rashes Diarrhea Canker sores Allergies Weight issues Frequent colds Afternoon energy slumps Headaches Other If other, please specify: Do you, or anyone in your immediate family have any health history with any of the following: * Cancer Heart Disease (Hypertension, High Cholesterol, Cardiovascular Disease) Alzheimer's Diabetes Stroke Depression Kidney Disease Arthritis/Sports Injuries Thyroid Other If other, please specify: Do you smoke cigarettes, vape or use cannabis at least once a week? * Yes No Height: * Weight: * Build Type * Lean Moderate Muscular What are your health and wellness goals? * Weight loss Muscle building Increased energy Improved flexibility/mobility Stress reduction Enhanced endurance General health and wellness Dietary improvements Other If other, please specify: How did you hear about us? * In-person Event LinkedIn Newsletter Google Search Tiktok Facebook Instagram Referral/Friend/Family X/Twitter Please enter referral's name * * I acknowledge that by completing this Health Risk Assessment, I am voluntarily disclosing personal health information. I give my consent for this information to be used for the purposes of assessing my health risks and providing personalized health recommendations. I understand that my information will be handled with confidentiality and in accordance with applicable privacy laws and regulations. Thank you for completing the online Health Risk Assessment. We are working hard behind the scenes to get your own Personalized healthcare blueprint and biometric test recommendations. Please be on the lookout in the next 2 hours from our admin@marqihealth.com email.
