METACOD — PATIENT INTAKE QUESTIONNAIRE

Full name · Age · Sex

General symptoms

Choose Yes or No for each line.

Nervous system & sensations

Choose Yes or No for each line.

Temperature, thirst & sweating

Choose Yes or No for each line.

Swelling, fluid & weight

Choose Yes or No for each line.

Skin, hair & nails

Choose Yes or No for each line.

Circulation & cold sensitivity

Choose Yes or No for each line.

Your patterns & triggers

Known diagnoses

Choose Yes or No for each line.

Current medications

Choose Yes or No for each line.

Mood (PHQ-9)

Over the last 2 weeks, how often have you been bothered by the following? Choose one box per line.

Anxiety (GAD-7)

Over the last 2 weeks, how often have you been bothered by the following? Choose one box per line.

Your lab values

Copy values from your lab report. Fill only what you have — blanks are fine.

What you take (name, dose):

Describe what bothers you — all your complaints in your own words:

📎 Attach photos (camera or gallery)

Attach clear photos: (a) your latest lab report, (b) any hospital report, (c) the affected skin/area, (d) a face photo only if you consent.

Photos are compressed automatically before sending (total limit 10 MB).