Leaky Gut Repair — Health Questionnaire

About you

We need this to ship your medication and verify your identity.

First name Last name Email Phone Date of birth Biological sex

Shipping address

Street address Apt / Suite (optional) City State ZIP

General health history

Basic background the physician needs to review.

Height (feet) Height (inches) Current weight (lbs) Target weight (lbs)

Current medications (include dose if known — separate with commas) Drug or food allergies Major medical conditions (current or past)

Leaky gut candidacy screening

A few targeted questions so the physician can evaluate your gut-barrier status and prescribe safely.

Primary symptom pattern — select all that apply (at least one required) Bloating after meals Irregular stools (loose, constipated, or alternating) Brain fog 30 min post-meal New food sensitivities Joint pain Skin issues (acne / eczema / rashes)

Diagnosed Crohn's disease, ulcerative colitis, or microscopic colitis? No Yes Unsure

Are you currently taking probiotics or fermented foods regularly? Yes, regularly No Stopped recently (within 30 days)

Have you taken antibiotics in the past 90 days? No Yes

Do you have a diagnosed autoimmune condition (Hashimoto's, RA, lupus, psoriasis, MS, etc.)? No Yes Unsure

Do you take NSAIDs (ibuprofen, aspirin, naproxen) regularly — more than 2x/week? No Yes

List any known food sensitivities, intolerances, or trigger foods (optional) Anything else the physician should know? (optional)

Your prescribed protocol

Based on your intake, one physician-reviewed protocol is available. Please review it below and confirm before continuing.

Biome NS Rx — Gut-Brain Repair Protocol

Biome NS Rx

Biome NS Rx — our proprietary compounded gut-repair prescription, written by the physician to your specific needs. Unique to My4MLife.

$129/month

Subscription delivers a 30-day supply with physician follow-up at month 3 and 6.

This is the only protocol available for your intake profile. By continuing you acknowledge the protocol above.

Save your payment method

⚡ Your card will not be charged today. It is saved securely with Stripe and will only be charged once a physician reviews your case and approves your script. If you are not approved, no charge is made.

By continuing you authorize My4MLife and our network physicians to use this saved payment method to charge your selected monthly subscription if and when a script is written for you. You can cancel anytime by emailing support@my4mlife.com.

Review and submit

Confirm everything looks right. After submission, our care coordinator will email you within 24 hours to confirm next steps with the network physician.

I attest the information above is accurate to the best of my knowledge. I understand a real physician will review my submission, and that no medication will ship without a written script. I authorize My4MLife and the network physician to contact me by email or phone. I acknowledge I have received and reviewed My4MLife's Notice of Privacy Practices. I authorize My4MLife and its network physicians to use and disclose my health information to provide, coordinate, and bill for my care, including forwarding my intake to the telemedicine provider, as described in the Patient Authorization & Telehealth Consent.

✓

Your submission is in.

Our care coordinator will email you within 24 hours to confirm the next step with the network physician. Your card has been saved securely with Stripe — no charge has been made and none will be made until your script is approved.

Questions? Email support@my4mlife.com.

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