Methylation Assessment

Clinical history and Undermethylation Epigenetic Driver screen. No Walsh biotype symptom questions.

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Enter the WalshDoc Patient ID and date of birth to reuse compatible prior information.

WalshDoc Patient ID

Date of Birth

Patient Information

Patient first name *

Patient last name *

Date of birth *

Gender *

Height *

Weight *

Primary contact email *

Phone

City

State

Country

Name and relationship of person completing this form

Condition, History, Meds and Supplements 5 items

Primary concern or chief complaint

Relevant clinical history

Prior medical diagnoses

Current medications and supplements

Medications taken for more than 60 days in the past

Family History 10 items

Item	Yes	No
Depression	Yes	No
Anxiety	Yes	No
OCD	Yes	No
Bipolar symptoms	Yes	No
Schizophrenia	Yes	No
Autism	Yes	No
ADHD	Yes	No
Alcoholism or substance abuse	Yes	No
Neurodegenerative disease (Parkinson's, Alzheimer's)	Yes	No
Other (describe)	Yes	No
Family history — Other (describe)

Early Life and Trauma History 6 items

Item	Yes	No
Difficult pregnancy or birth	Yes	No
Mother smoked, drank alcohol, or used medications/drugs during pregnancy	Yes	No
Childhood abuse or neglect	Yes	No
Adulthood abuse or trauma	Yes	No
Serious reaction to a vaccine	Yes	No
Head trauma or concussion	Yes	No

Childhood Health History 5 items

Item	Yes	No
Frequent antibiotic use	Yes	No
Frequent medication use	Yes	No
Delayed growth	Yes	No
Social interaction difficulties	Yes	No
Behavioral or violent tendencies	Yes	No

Tobacco / Alcohol / Substance Use 7 items

Item	Yes	No
Current cigarette use	Yes	No
Past cigarette use	Yes	No
Vaping or nicotine products	Yes	No
Alcohol use (current)	Yes	No
Alcohol use (past heavy use)	Yes	No
Past or present use of recreational or street drugs	Yes	No
Current cannabis use	Yes	No

Environmental Exposures 9 items

Item	Yes	No	N/A
Living or working in a moldy or water-damaged environment	Yes	No	N/A
Use of well water	Yes	No	N/A
Exposure to chemicals (cleaners, pesticides, solvents, plastics)	Yes	No	N/A
Exposure to metals (occupational, welding, industrial materials)	Yes	No	N/A
Sensitivity to smells, chemicals, or environments	Yes	No	N/A
Symptoms that worsen in certain buildings or environments	Yes	No	N/A
Water-damaged building without obvious mold growth	Yes	No	N/A
Dental occupation or frequent dental-material exposure	Yes	No	N/A
Other (describe)	Yes	No	N/A
Environmental exposures — Other (describe)

Typical Daily Intake 5 items

Typical breakfast

Typical lunch

Typical dinner

Snacks

Beverages (water, coffee, soda, alcohol, etc.)

Dietary Habits / Food Frequency 5 items

Item	Rare	Occasional	Frequent
Corn-based foods	Rare	Occasional	Frequent
Wheat / gluten-containing foods	Rare	Occasional	Frequent
Dairy products	Rare	Occasional	Frequent
Soy products	Rare	Occasional	Frequent
Meat, fish, pork, or chicken	Rare	Occasional	Frequent

Dietary Patterns 9 items

Item	Yes	No
Frequent consumption of sugary foods or desserts	Yes	No
Frequent consumption of sweetened beverages (soda, juice, energy drinks)	Yes	No
Frequent fast food intake	Yes	No
Frequent consumption of processed or packaged foods	Yes	No
Frequent consumption of processed meats (deli meats, bacon, sausage)	Yes	No
Frequent consumption of highly flavored or artificial foods	Yes	No
Low-meat, vegetarian, or vegan diet	Yes	No
Low total protein intake	Yes	No
Other (describe)	Yes	No
Dietary patterns — Other (describe)

Gut Health 10 items

Item	Yes	No
Bloating	Yes	No
Gas	Yes	No
Constipation	Yes	No
Diarrhea	Yes	No
Irregular bowel movements	Yes	No
Food sensitivities	Yes	No
Nausea (especially morning)	Yes	No
Reflux or heartburn	Yes	No
Malodorous (foul-smelling) stool	Yes	No
Other (describe)	Yes	No
Gut health — Other (describe)

EPIGENETIC BIOTYPE QUESTIONS 7 sections

Additional medical, medication, infection, and recovery history.

Mental and Physical Stamina 17 items

Describe relevant details or other concerns

Chronic Medical Conditions

No Yes

Current Medications

No Yes

Infections and Immune History

No Yes

Neurologic History

No Yes

Kidney, Fluid, and Clearance

No Yes

Sleep and Breathing

No Yes

Symptoms worsen after physical or mental exertion	Yes	No
Low endurance despite adequate sleep and nutrition	Yes	No
Unrefreshed after adequate sleep	Yes	No
Difficulty maintaining daytime energy	Yes	No
Poor recovery after exercise, illness, or stress	Yes	No
Mental exhaustion after concentration	Yes	No
Afternoon or early-evening energy decline	Yes	No
Declining exercise tolerance	Yes	No
Difficulty maintaining muscle mass	Yes	No
Reduced strength	Yes	No
Poor recovery between physical efforts	Yes	No
Prolonged muscle soreness after activity	Yes	No
Rapid fatigue during short, intense activity	Yes	No
Physically demanding work or regular high-intensity training	Yes	No
Prolonged inactivity, rehabilitation, or loss of conditioning	Yes	No
Major surgery or prolonged physical recovery in the past year	Yes	No
High cognitive demand	Yes	No

Diabetes, prediabetes, or insulin resistance	Yes	No
Metabolic syndrome or central weight gain	Yes	No
Cardiomyopathy, heart failure, or reduced cardiac function	Yes	No
Postural orthostatic tachycardia syndrome or dysautonomia	Yes	No
Need for high salt, electrolytes, or fluids with dizziness on standing	Yes	No
Myalgic encephalomyelitis / chronic fatigue syndrome	Yes	No
Active cancer	Yes	No
Prior cancer history	Yes	No

Cholesterol-lowering medication	Yes	No
Diabetes medication	Yes	No
Acid-reducing medication	Yes	No
Psychiatric medication	Yes	No
Stimulant medication	Yes	No
Anticonvulsant medication	Yes	No
Sedative, benzodiazepine, or opioid	Yes	No
Steroid or immunosuppressant	Yes	No
Diuretic	Yes	No
Chemotherapy or cancer treatment	Yes	No
Frequent nonsteroidal anti-inflammatory drug use	Yes	No
Frequent acetaminophen use	Yes	No
Multiple prescription medications	Yes	No
Other medication	Yes	No

Epstein–Barr virus or mononucleosis	Yes	No
Long COVID or persistent symptoms after viral illness	Yes	No
Lyme disease or another tick-borne infection	Yes	No
Frequent or difficult-to-clear infections	Yes	No
Chronic sinus, dental, urinary, or digestive infection	Yes	No
Recurrent strep or PANS/PANDAS pattern	Yes	No
Chronic fungal or yeast infection	Yes	No
Parasitic infection	Yes	No
Autoimmune illness	Yes	No
Chronic inflammatory illness	Yes	No
Eczema or psoriasis	Yes	No
Hives or recurrent skin reactions	Yes	No

Traumatic brain injury or concussion	Yes	No
Stroke or transient ischemic attack	Yes	No
Seizure history	Yes	No
Parkinson's disease	Yes	No
Dementia or cognitive decline	Yes	No
Other neurodegenerative condition	Yes	No

Chronic kidney disease or reduced kidney function	Yes	No
History of elevated creatinine or reduced eGFR	Yes	No
Protein or albumin found in the urine	Yes	No
Persistent ankle, leg, or generalized swelling	Yes	No
Noticeably reduced urine output	Yes	No
Recurrent kidney stones	Yes	No
Frequent dehydration or difficulty maintaining hydration	Yes	No
Abnormal sodium, potassium, or other electrolyte levels	Yes	No
Dialysis or prior significant kidney injury	Yes	No

Diagnosed sleep apnea	Yes	No
Loud habitual snoring	Yes	No
Someone has noticed pauses in breathing during sleep	Yes	No
Waking choking, gasping, or short of breath	Yes	No
Morning headaches or dry mouth	Yes	No
Excessive daytime sleepiness despite enough time in bed	Yes	No
Chronic obstructive pulmonary disease or emphysema	Yes	No
Known low oxygen levels	Yes	No
Shortness of breath limiting routine activity	Yes	No