mutation CreateIntakeForm {
  createCustomModuleForm(input: {
    name: "MetaFlow Enrollment Assessment"
    custom_modules: [{"hipaa_name": "i_have_read_and_understand_the_eligibility_assessment", "mod_type": "choice", "label": "I have read and understand the Eligibility Assessment.", "required": true, "options": ["Yes", "No"]}, {"hipaa_name": "name_entry_number_first", "mod_type": "text", "label": "First Name", "required": true}, {"hipaa_name": "name_entry_number_middle", "mod_type": "text", "label": "Middle Name", "required": false}, {"hipaa_name": "name_entry_number_last", "mod_type": "text", "label": "Last Name", "required": true}, {"hipaa_name": "sex_on_medical_or_lab_records", "mod_type": "text", "label": "Sex on Medical or Lab Records", "required": false, "description": "Please select the sex listed on your medical, insurance, or laboratory records. This is required so we can route you to the appropriate clinical assessment questions."}, {"hipaa_name": "date_of_birth", "mod_type": "date", "label": "Date of Birth", "required": false, "description": "Please enter your date of birth as it appears on your medical, insurance, or laboratory records."}, {"hipaa_name": "email", "mod_type": "text", "label": "Email", "required": false, "description": "Please use an email address you can access. We may use this email for secure form links, assessment updates, or account setup if you are accepted for further review."}, {"hipaa_name": "phone", "mod_type": "text", "label": "Phone", "required": false, "description": "Please enter a mobile phone number where our team may contact you about your assessment or request missing information."}, {"hipaa_name": "address_line1", "mod_type": "text", "label": "Address Line 1", "required": true}, {"hipaa_name": "address_line2", "mod_type": "text", "label": "Address Line 2", "required": false}, {"hipaa_name": "address_city", "mod_type": "text", "label": "City", "required": true}, {"hipaa_name": "address_state", "mod_type": "text", "label": "State", "required": true}, {"hipaa_name": "address_postal_code", "mod_type": "text", "label": "ZIP / Postal Code", "required": true}, {"hipaa_name": "address_country", "mod_type": "text", "label": "Country", "required": false}, {"hipaa_name": "do_any_of_the_above_current_conditions_apply_to_you", "mod_type": "choice", "label": "Do any of the above current conditions apply to you?", "required": false, "options": ["Yes", "No"]}, {"hipaa_name": "pre_enrollment_acknowledgment", "mod_type": "choice", "label": "Pre-Enrollment Acknowledgment", "required": false, "description": "Your acknowledgment is required before continuing with the assessment.", "options": ["Yes, I understand and agree to continue.", "No, I do not wish to continue at this time."]}, {"hipaa_name": "what_health_concerns_would_you_most_like_meta_flow_to_help_you_track_or_improve", "mod_type": "checkbox", "label": "What health concerns would you most like MetaFlow to help you track or improve?", "required": false, "description": "multiple choice", "options": ["Blood sugar abnormalities, such as diabetes, impaired glucose tolerance, or elevated HbA1c", "Blood pressure abnormalities, such as high blood pressure or significant blood pressure fluctuations", "Lipid abnormalities, such as elevated LDL-C, triglycerides, total cholesterol, or ApoB", "Kidney-related markers, such as abnormal urine protein, uACR, creatinine, or eGFR", "Fatty liver, abnormal liver enzymes, or metabolic dysfunction-associated fatty liver disease", "Weight, waist circumference, abdominal fat, or metabolic syndrome-related concerns", "Carotid plaque, subclavian artery plaque, or arteriosclerosis", "Vascular narrowing, abnormal blood flow, or physician-noted vascular risk", "Thyroid nodules, breast nodules, or other nodules found on ultrasound", "Gallstones, kidney stones, or other imaging abnormalities", "Chronic neck, shoulder, low back, leg, or limb pain", "Joint pain, stiffness, or limited range of motion", "Muscle soreness, numbness, tingling, or fixed pain points", "Existing diagnosis of chronic musculoskeletal pain", "Skin concerns, such as eczema, hives, acne, psoriasis, or recurring itching", "Female health concerns, such as menstrual issues, vaginal discharge, fibroids, adenomyosis, PCOS, endometriosis, or related conditions", "Male reproductive, prostate, or urogenital health concerns", "Sleep problems, anxiety, fatigue, emotional tension, or long-term stress", "Other metabolic, pain-related, immune-related, or chronic physical concerns"]}, {"hipaa_name": "how_long_have_these_concerns_or_symptoms_been_present", "mod_type": "choice", "label": "How long have these concerns or symptoms been present?", "required": false, "options": ["Less than 1 month", "1\u20136 months", "6\u201312 months", "1\u20133 years", "More than 3 years", "Not sure"]}, {"hipaa_name": "other_concerns", "mod_type": "text", "label": "Other Concerns", "required": false, "max_length": 100}, {"hipaa_name": "what_physical_symptoms_or_sensations_are_currently_bothering_you_the_most", "mod_type": "text", "label": "What physical symptoms or sensations are currently bothering you the most?", "required": false, "description": "Please describe this in your own words.Examples may include: feeling very tired after meals, bitter taste in the mouth upon waking, bloating, chest tightness, fixed stabbing pain in a specific area, cold soreness in the lower back or knees, waking up at night due to pain, foamy urine, recurring skin itching, or any other symptoms that feel important to you.", "max_length": 500}, {"hipaa_name": "which_of_the_following_digestive_patterns_do_you_commonly_experience", "mod_type": "checkbox", "label": "Which of the following digestive patterns do you commonly experience?", "required": false, "description": "multiple choice", "options": ["Bloating or stomach fullness after meals, especially after eating too much or eating late", "Acid reflux, heartburn, or sour fluid rising from the stomach", "Belching, burping, hiccups, or a feeling of gas rising upward", "Significant sleepiness, brain fog, or heaviness after meals", "Bloating, nausea, or diarrhea after eating greasy or oily foods", "Stomach pain, abdominal pain, or diarrhea after eating cold or raw foods", "Poor appetite, rarely feeling hungry, or feeling full after eating only a small amount", "Frequent constipation or dry stools", "Often no urge to have a bowel movement, or irregular bowel movements", "Frequent diarrhea or loose/unformed stools", "Digestion is generally good, with no significant gastrointestinal discomfort"]}, {"hipaa_name": "have_you_ever_been_diagnosed_by_a_physician_with_any_of_the_following_digestive_conditions", "mod_type": "checkbox", "label": "Have you ever been diagnosed by a physician with any of the following digestive conditions?", "required": false, "description": "multiple choice", "options": ["Gastritis", "Stomach ulcer / gastric ulcer", "Reflux esophagitis / GERD", "Atrophic gastritis", "Irritable bowel syndrome / IBS", "Inflammatory bowel disease, such as Crohn\u2019s disease or ulcerative colitis", "Cholecystitis, gallstones, or history of gallbladder removal", "Gastrointestinal polyps or other gastrointestinal disease", "No confirmed digestive diagnosis"]}, {"hipaa_name": "which_of_the_following_best_describe_your_usual_diet_and_lifestyle_patterns", "mod_type": "checkbox", "label": "Which of the following best describe your usual diet and lifestyle patterns?", "required": false, "options": ["Frequently drinks iced beverages or eats cold/raw foods", "Often eats sweets, refined carbohydrates, pastries, or sugary drinkss", "Often eats greasy, fried, oily, or high-salt foods", "Often eats spicy or strongly flavored foods", "Rarely eats vegetables or fiber-rich foods", "Relies on coffee or strong tea, more than 2 cups per day", "Often eats late dinners or late-night snacks", "Often skips breakfast or has irregular meal timing", "Drinks alcohol frequently or drinks more than usual recently", "Diet is generally regular and balanced, with no obvious concerns"]}, {"hipaa_name": "is_there_anything_else_you_would_like_to_add_about_your_digestion_diet_or_postmeal_energy", "mod_type": "text", "label": "Is there anything else you would like to add about your digestion, diet, or post-meal energy?", "required": false, "description": "150-word maximum"}, {"hipaa_name": "which_of_the_following_best_describe_your_typical_bowel_movements", "mod_type": "checkbox", "label": "Which of the following best describe your typical bowel movements?", "required": false, "options": ["Dry, hard stools, pellet-like stools, or straining during bowel movements", "Sticky stools that often stick to the toilet and are difficult to flush", "Loose, watery, mushy, or unformed stools", "Alternating dry and loose stools, or stools that start dry and later become loose", "More than 2 bowel movements per day", "No urge to have a bowel movement or inability to pass stool for more than 3 consecutive days", "Black or tarry stools that cannot be explained by diet, iron supplements, or medications", "Bright red blood in stool or recurring rectal bleeding", "Bowel movements are generally normal"]}, {"hipaa_name": "do_you_have_hemorrhoids_or_analperianal_issues", "mod_type": "choice", "label": "Do you have hemorrhoids or anal/perianal issues?", "required": false, "options": ["No", "Yes, occasional discomfort", "Yes, frequent swelling, pain, or bleeding", "Not sure"]}, {"hipaa_name": "which_of_the_following_best_describe_your_typical_urination_pattern", "mod_type": "checkbox", "label": "Which of the following best describe your typical urination pattern?", "required": false, "options": ["Dark yellow urine or reduced urine amount", "Pain, burning, or discomfort during urination", "Very clear urine, large urine volume, or noticeably frequent urination", "Frequent nighttime urination, waking up 2 or more times per night to urinate", "Foamy urine that does not disappear quickly", "Difficulty urinating, incomplete emptying, or a weak/narrow urine stream", "Blood in urine, or urine that looks tea-colored or cola-colored", "Urination is generally normal, with clear light-yellow urine"]}, {"hipaa_name": "is_there_anything_else_you_would_like_to_add_about_bowel_movements_urination_swelling_fluid_balance_or_metabolic_patterns", "mod_type": "text", "label": "Is there anything else you would like to add about bowel movements, urination, swelling, fluid balance, or metabolic patterns?", "required": false, "description": "150-word maximumExamples may include ankle swelling, puffy eyelids in the morning, a heavy body sensation, feeling thirsty despite drinking water, or increased urination at night."}, {"hipaa_name": "which_option_best_describes_your_current_menstrual_status", "mod_type": "choice", "label": "Which option best describes your current menstrual status?", "required": false, "options": ["Regular cycles", "Often early", "Often delayed", "Very irregular cycles", "No menstrual period for more than 3 consecutive months", "Continuous or prolonged abnormal bleeding", "Postmenopausal", "Not applicable or not sure"]}, {"hipaa_name": "how_would_you_describe_your_usual_menstrual_flow", "mod_type": "choice", "label": "How would you describe your usual menstrual flow?", "required": false, "options": ["Generally normal", "Light; flow significantly decreases or ends within 1\u20132 days", "Heavy; requires frequent pad/tampon changes or the period lasts noticeably longer than usual", "Flow varies significantly from cycle to cycle", "Not applicable or not sure"]}, {"hipaa_name": "what_color_is_your_menstrual_blood_usually_closest_to", "mod_type": "checkbox", "label": "What color is your menstrual blood usually closest to?", "required": false, "description": "multiple choice", "options": ["Bright red", "Dark red", "Purple-black or noticeably dark", "Pale red or very light-colored", "Brown or coffee-colored", "Not applicable or not sure"]}, {"hipaa_name": "which_of_the_following_apply_to_menstrual_clots_cramps_or_abnormal_bleeding", "mod_type": "checkbox", "label": "Which of the following apply to menstrual clots, cramps, or abnormal bleeding?", "required": false, "options": ["Almost no clots and no menstrual cramps", "Frequent blood clots during menstruation", "Abdominal pain improves after clots are passed", "Mild cramps that are tolerable and do not interfere with daily life", "Moderate to severe cramps requiring pain medication, or cramps associated with cold hands/feet, nausea, or vomiting", "Abnormal bleeding between menstrual periods", "Bleeding after menopause", "Not applicable or not sure"]}, {"hipaa_name": "which_of_the_following_apply_to_vaginal_discharge_or_privatearea_discomfort", "mod_type": "checkbox", "label": "Which of the following apply to vaginal discharge or private-area discomfort?", "required": false, "description": "multiple choice", "options": ["Noticeably increased discharge that often soaks underwear", "Yellow, green, or cottage-cheese-like discharge", "Noticeable odor", "Itching, burning, stinging, or pain in the private area", "Discharge is generally normal, with no noticeable odor or itching", "Not applicable or not sure"]}, {"hipaa_name": "have_you_ever_been_diagnosed_with_or_had_a_history_of_any_of_the_following", "mod_type": "checkbox", "label": "Have you ever been diagnosed with or had a history of any of the following?", "required": false, "description": "multiple choice", "options": ["Uterine fibroids", "Uterine or cervical polyps", "Adenomyosis", "Ovarian endometrioma / endometriosis", "Polycystic ovary syndrome (PCOS)", "Persistent high-risk HPV positivity", "Cervical intraepithelial neoplasia (CIN)", "Chronic pelvic inflammatory disease, adnexitis, or pelvic fluid/effusion", "A physician has indicated difficulty conceiving, infertility, or ovulation abnormality", "History of miscarriage, missed miscarriage, stillbirth, or ectopic pregnancy", "History of C-section or other gynecologic surgery", "None of the above", "Not sure"]}, {"hipaa_name": "is_there_anything_else_you_would_like_to_add_about_your_gynecologic_health_reproductive_health_or_menstrual_status", "mod_type": "text", "label": "Is there anything else you would like to add about your gynecologic health, reproductive health, or menstrual status?", "required": false, "max_length": 200}, {"hipaa_name": "upload_female_health_gynecologic_cervical_or_breast_reports", "mod_type": "file", "label": "Upload Female Health, Gynecologic, Cervical, or Breast Reports", "required": false, "description": "Please upload any relevant female health reports if available.Reports from the past 3 months are preferred. Accepted examples include PDF reports, screenshots, scanned reports, or clear photos of the report. This upload is optional but strongly recommended if you have a history of HPV, abnormal Pap smear, CIN, fibroids, adenomyosis, endometriosis, ovarian cysts, breast nodules, postmenopausal bleeding, or other female health concerns.", "max_length": 8}, {"hipaa_name": "have_you_ever_been_diagnosed_with_or_told_you_may_have_any_prostaterelated_condition", "mod_type": "checkbox", "label": "Have you ever been diagnosed with or told you may have any prostate-related condition?", "required": false, "description": "multiple choice", "options": ["Enlarged prostate / benign prostatic hyperplasia (BPH)", "Prostatitis", "Elevated PSA", "Prostate nodules or abnormal prostate exam", "Prostate cancer history", "Prostate procedure or surgery", "None of the above", "Not sure"]}, {"hipaa_name": "which_of_the_following_apply_to_your_sexual_function", "mod_type": "checkbox", "label": "Which of the following apply to your sexual function?", "required": false, "description": "multiple choice", "options": ["No significant sexual function concerns", "Difficulty getting an erection", "Difficulty maintaining an erection", "Erection is not firm enough for intercourse", "Low sexual desire / low libido", "Diagnosed low testosterone", "Sexual fatigue or reduced sexual stamina", "Prefer not to answer"]}, {"hipaa_name": "which_of_the_following_apply_to_ejaculation_or_semenrelated_concerns", "mod_type": "checkbox", "label": "Which of the following apply to ejaculation or semen-related concerns?", "required": false, "description": "multiple choice", "options": ["No significant ejaculation or semen-related concerns", "Premature ejaculation", "Delayed ejaculation", "Weak or reduced ejaculation force", "Pain or discomfort with ejaculation", "Blood in semen", "Low semen volume", "Diagnosed low sperm count", "Diagnosed low sperm motility", "Fertility or conception concerns", "Prefer not to answer"]}, {"hipaa_name": "do_you_have_any_perineal_testicular_scrotal_or_groin_symptoms", "mod_type": "checkbox", "label": "Do you have any perineal, testicular, scrotal, or groin symptoms?", "required": false, "description": "multiple choice", "options": ["No significant symptoms", "Perineal dampness or discomfort", "Perineal itching, burning, or irritation", "Testicular or scrotal pain", "Testicular or scrotal swelling", "Lump or mass in the testicle, scrotum, or groin", "Varicocele history", "Hydrocele history", "Hernia history", "Not sure"]}, {"hipaa_name": "have_you_had_any_male_reproductive_urologic_or_pelvic_surgery_or_procedure", "mod_type": "checkbox", "label": "Have you had any male reproductive, urologic, or pelvic surgery or procedure?", "required": false, "description": "multiple choice", "options": ["Vasectomy", "Prostate procedure or surgery", "Testicular or scrotal surgery", "Hernia repair", "Pelvic surgery", "Radiation therapy involving the pelvis or prostate", "None of the above"]}, {"hipaa_name": "are_you_currently_trying_to_conceive_or_planning_fertility_evaluation", "mod_type": "choice", "label": "Are you currently trying to conceive or planning fertility evaluation?", "required": false, "options": ["Yes", "No", "Not currently, but I have had fertility concerns in the past", "Prefer not to answer"]}, {"hipaa_name": "is_there_anything_else_you_would_like_to_add_about_urinary_prostate_sexual_fertility_or_male_reproductive_health", "mod_type": "text", "label": "Is there anything else you would like to add about urinary, prostate, sexual, fertility, or male reproductive health?", "required": false, "max_length": 200}, {"hipaa_name": "upload_male_reproductive_prostate_urologic_or_fertility_reports", "mod_type": "file", "label": "Upload Male Reproductive, Prostate, Urologic, or Fertility Reports", "required": false, "description": "Please upload any relevant male health reports if available.Reports from the past 3 months are preferred. If your most recent report is older, you may still upload it. Accepted examples include PDF reports, screenshots, scanned reports, or clear photos of the report. This upload is optional but strongly recommended if you have a history of elevated PSA, prostatitis, enlarged prostate / BPH, prostate cancer, fertility concerns, low sperm motility, low testosterone, testicular or scrotal symptoms, varicocele, hydrocele, hernia, or prior male reproductive/urologic surgery.", "max_length": 8}, {"hipaa_name": "which_of_the_following_mouth_or_throat_symptoms_do_you_commonly_experience", "mod_type": "checkbox", "label": "Which of the following mouth or throat symptoms do you commonly experience?", "required": false, "options": ["Dry mouth that is not easily relieved by drinking water", "Bitter taste in the mouth, especially upon waking", "Noticeable bad breath", "Recurrent mouth ulcers", "A sensation of something stuck in the throat, as if it cannot be swallowed or cleared", "Chronic throat irritation, itchiness, or dryness", "Phlegm in the throat that can be coughed up", "Post-nasal drip or mucus dripping from the nose into the throat", "No significant mouth or throat discomfort"]}, {"hipaa_name": "if_you_cough_up_phlegm_which_description_is_closest", "mod_type": "checkbox", "label": "If you cough up phlegm, which description is closest?", "required": false, "options": ["No phlegm", "White, thin, or watery phlegm", "White, thick, sticky phlegm that is difficult to cough up", "Yellow, yellow-green, or pus-like phlegm", "Occasional blood streaks in phlegm", "Frequent or large amounts of phlegm", "Phlegm is mainly present in the morning"]}, {"hipaa_name": "which_of_the_following_eye_symptoms_do_you_commonly_experience", "mod_type": "checkbox", "label": "Which of the following eye symptoms do you commonly experience?", "required": false, "options": ["Dry eyes", "Eye pressure, soreness, or aching", "Tearing when exposed to wind", "Frequent redness or visible blood vessels in the eyes", "Light sensitivity", "Recent noticeable change in vision", "No significant eye concerns"]}, {"hipaa_name": "which_of_the_following_nose_or_breathingrelated_symptoms_do_you_commonly_experience", "mod_type": "checkbox", "label": "Which of the following nose or breathing-related symptoms do you commonly experience?", "required": false, "options": ["Frequent sneezing or clear runny nose", "Frequent thick yellow nasal discharge", "Frequent nasal congestion", "Post-nasal drip", "Noticeable snoring at night", "A family member or housemate has observed pauses in breathing, choking, gasping, or waking up short of breath during sleep", "No significant nasal concerns"]}, {"hipaa_name": "which_of_the_following_ear_symptoms_do_you_commonly_experience", "mod_type": "checkbox", "label": "Which of the following ear symptoms do you commonly experience?", "required": false, "options": ["Ringing in the ears with a high-pitched sound", "Ringing in the ears with a low or deep sound", "Intermittent hearing reduction", "Ear fullness or pressure", "History of chronic middle ear infection", "No significant ear concerns"]}, {"hipaa_name": "do_you_commonly_experience_headaches_dizziness_nausea_or_vomiting", "mod_type": "checkbox", "label": "Do you commonly experience headaches, dizziness, nausea, or vomiting?", "required": false, "options": ["Frequent headaches", "Frequent dizziness or vertigo", "Headache with nausea or vomiting", "Headache mainly in the forehead area", "Headache mainly around the temples", "Headache mainly in the back of the head or neck area", "A recent sudden, severe headache that is completely different from your usual headaches", "No significant headache or dizziness"]}, {"hipaa_name": "is_there_anything_else_you_would_like_to_add_about_your_mouth_throat_eyes_nose_ears_headaches_or_dizziness", "mod_type": "text", "label": "Is there anything else you would like to add about your mouth, throat, eyes, nose, ears, headaches, or dizziness?", "required": false, "max_length": 200}, {"hipaa_name": "which_of_the_following_best_describe_your_sweating_pattern_and_temperature_sensitivity", "mod_type": "checkbox", "label": "Which of the following best describe your sweating pattern and temperature sensitivity?", "required": false, "options": ["It is difficult for me to sweat, even with exercise, hot weather, or warm baths", "I sweat heavily with only mild activity", "My palms or soles often feel hot, or I feel heat/restlessness in the chest or upper abdomen", "I often experience heat episodes, facial flushing, or hot flashes in the afternoon or evening", "I sweat during sleep at night, and the sweating stops after I wake up", "I often feel cold, especially with cold hands or feet", "My upper body tends to feel hot, while my lower body or feet feel cold", "My temperature sensation is generally normal, with no significant cold/heat sensitivity or abnormal sweating"]}, {"hipaa_name": "which_of_the_following_commonly_apply_to_your_face_scalp_or_hair", "mod_type": "checkbox", "label": "Which of the following commonly apply to your face, scalp, or hair?", "required": false, "options": ["Noticeably oily facial skin", "Itchy scalp or noticeably increased dandruff", "Hair becomes oily very quickly, such as flattening within one day without washing", "Noticeable hair loss, receding hairline, or thinning on the top of the head", "Face easily becomes red or flushed", "Facial complexion appears yellowish, dull, dark, or lacking brightness", "No significant face, scalp, or hair concerns"]}, {"hipaa_name": "which_of_the_following_skin_patterns_apply_to_you", "mod_type": "checkbox", "label": "Which of the following  skin patterns apply to you?", "required": false, "options": ["Atopic dermatitis", "Chronic or year-round eczema", "Recurrent hives / urticaria", "Diagnosed psoriasis", "Chronic itchy rash or neurodermatitis / lichen simplex chronicus", "Recurrent unexplained itching, especially worse at night or during seasonal changes", "Skin is easily allergic, red, irritated, or prone to rashes", "Dry skin with noticeable scaling or peeling", "Athlete\u2019s foot / tinea pedis", "Hand fungal infection / tinea manuum", "Other fungal skin infection", "No significant skin concerns"]}, {"hipaa_name": "have_you_used_any_of_the_following_longterm_for_skin_immune_inflammatory_or_autoimmune_conditions", "mod_type": "checkbox", "label": "Have you used any of the following long-term for skin, immune, inflammatory, or autoimmune conditions?", "required": false, "options": ["Long-term topical steroid creams or ointments", "Long-term oral or injectable steroids, such as prednisone, methylprednisolone, or dexamethasone", "Long-term immunosuppressants, such as tacrolimus, cyclosporine, mycophenolate, methotrexate, azathioprine, or similar medications", "Biologic medications or JAK inhibitors, such as adalimumab, dupilumab, infliximab, etanercept, rituximab, tocilizumab, tofacitinib, or similar medications", "I have used these medications in the past, but not currently", "No, none of the above"]}, {"hipaa_name": "is_there_anything_else_you_would_like_to_add_about_sweating_skin_hair_fungal_infections_medication_use_or_temperature_sensitivity", "mod_type": "text", "label": "Is there anything else you would like to add about sweating, skin, hair, fungal infections, medication use, or temperature sensitivity?", "required": false, "description": "150-word maximum", "max_length": 150}, {"hipaa_name": "which_of_the_following_best_describe_your_sleep_quality", "mod_type": "checkbox", "label": "Which of the following best describe your sleep quality?", "required": false, "options": ["Difficulty falling asleep; it often takes more than 30 minutes to fall asleep", "Frequent dreams throughout the night, waking up feeling as if I did not sleep enough", "Very light sleep; I wake up easily from small sounds or movements", "Waking up at a similar time during the night", "Often waking around 1:00 AM", "Often waking around 3:00 AM", "Often waking around 5:00 AM", "Feeling heat, burning, or discomfort in the stomach during insomnia", "Early-morning awakening and difficulty falling back asleep", "Frequently unable to sleep through most of the night", "Long-term use of sleep medications, sedatives, or calming medications to sleep", "Sleep is generally good, and I wake up feeling rested"]}, {"hipaa_name": "which_of_the_following_best_describe_your_recent_stress_or_emotional_state", "mod_type": "checkbox", "label": "Which of the following best describe your recent stress or emotional state?", "required": false, "options": ["Chest tightness or feeling the need to sigh deeply to feel comfortable", "Easily anxious, tense, or constantly worried", "Difficulty relaxing; my body feels tense for long periods", "Difficulty relaxing; my body feels tense for long periods", "Easily irritable or angry over small things", "Easily startled; sudden sounds may make my heart race", "Frequent palpitations, fast heartbeat, or an empty feeling in the chest", "Fatigue, low motivation, or loss of interest in many things", "My mood is generally stable, with no major emotional concerns"]}, {"hipaa_name": "is_there_anything_else_you_would_like_to_add_about_sleep_stress_mood_or_emotional_state", "mod_type": "text", "label": "Is there anything else you would like to add about sleep, stress, mood, or emotional state?", "required": false, "description": "150-word maximum", "max_length": 150}, {"hipaa_name": "weight_in_pounds", "mod_type": "text", "label": "Weight in pounds", "required": false}, {"hipaa_name": "height_in_inches", "mod_type": "text", "label": "Height in inches", "required": false, "description": "Please enter your total height in inches. For example, if you are 5'6\", enter 66."}, {"hipaa_name": "waist_circumference", "mod_type": "text", "label": "Waist circumference", "required": false, "description": "Waist circumference in inches"}, {"hipaa_name": "weight_change_over_the_past6_months", "mod_type": "choice", "label": "Weight change over the past 6 months", "required": false, "options": ["Mostly stable", "Increased by more than 5 lb / 2.5 kg", "Decreased by more than 5 lb / 2.5 kg", "Not sure"]}, {"hipaa_name": "which_of_the_following_best_describe_your_weightcontrol_or_eatingcontrol_patterns", "mod_type": "checkbox", "label": "Which of the following best describe your weight-control or eating-control patterns?", "required": false, "options": ["I gain weight easily", "It is difficult for me to lose weight even with diet or exercise efforts", "I feel that I gain weight even when I do not eat very much", "I have difficulty controlling my appetite", "I sometimes have episodes of overeating or feeling unable to stop eating", "I often crave sweets, refined carbohydrates, or snacks", "My weight is generally easy to manage"]}, {"hipaa_name": "which_option_best_describes_your_usual_physical_activity_level", "mod_type": "choice", "label": "Which option best describes your usual physical activity level?", "required": false, "options": ["Occasional walking or light activity, less than 2 times per week", "Almost no exercise; mostly sedentary", "Regular exercise 2\u20133 times per week", "Regular exercise 4 or more times per week", "I used to exercise more, but recently reduced activity due to pain, fatigue, or illness", "Not sure"]}, {"hipaa_name": "what_types_of_physical_activity_do_you_currently_do", "mod_type": "checkbox", "label": "What types of physical activity do you currently do?", "required": false, "options": ["Walking", "Brisk walking", "Running", "Cycling", "Swimming", "Yoga / Pilates / stretching", "Strength training / weight training", "Ball sports", "Tai chi / low-intensity body practice", "Frequent housework or physical labor", "Almost no physical activity"]}, {"hipaa_name": "how_does_your_body_usually_respond_after_physical_activity", "mod_type": "checkbox", "label": "How does your body usually respond after physical activity?", "required": false, "options": ["I feel more energized or physically lighter after activity", "I feel easily exhausted and recover slowly after activity", "I experience palpitations, chest tightness, or shortness of breath after activity", "My pain becomes noticeably worse after activity", "I sweat excessively or feel weak/depleted after activity", "I feel dizzy or as if my blood sugar is low after activity", "I currently avoid exercise because of pain or physical discomfort", "I do not exercise enough to judge"]}, {"hipaa_name": "where_do_you_commonly_experience_soreness_tightness_pain_numbness_stiffness_or_weakness", "mod_type": "checkbox", "label": "Where do you commonly experience soreness, tightness, pain, numbness, stiffness, or weakness?", "required": false, "options": ["Neck pain, stiffness, or limited range of motion", "Shoulder pain or difficulty lifting the arm", "Fixed pain point or heaviness near the shoulder blade or upper back", "Chest pain, stabbing pain, pressure, or tightness", "Rib-area tightness or pain, especially worse with emotional stress", "Upper back pain", "Low back pain, soreness, or stiffness", "Hip pain or limited hip mobility", "Knee pain, cold sensation, weakness, soreness, or limited movement", "Ankle, sole, foot, or toe pain", "Numbness, tingling, or electric-shock-like sensations in the arms or legs", "Fixed stabbing pain in one location, especially worse at night", "Migrating pain throughout the body that changes location", "Long-term coldness in the lower legs or feet that is not easily relieved by warming", "No significant body pain"]}, {"hipaa_name": "have_you_ever_been_diagnosed_by_a_physician_with_any_of_the_following", "mod_type": "checkbox", "label": "Have you ever been diagnosed by a physician with any of the following?", "required": false, "options": ["Cervical spondylosis / cervical disc herniation", "Lumbar disc herniation", "Scoliosis or spinal degeneration", "Knee degenerative changes / osteoarthritis", "Synovitis", "Frozen shoulder / rotator cuff injury", "Ankylosing spondylitis", "Rheumatoid arthritis", "Gout", "Osteoporosis", "Neuropathy or nerve compression", "Fibromyalgia", "Diagnosis pending or not yet confirmed by a physician", "No confirmed diagnosis"]}, {"hipaa_name": "do_you_have_a_clear_history_of_sports_injury_trauma_or_physical_injury", "mod_type": "checkbox", "label": "Do you have a clear history of sports injury, trauma, or physical injury?", "required": false, "options": ["Sprain, strain, fall, or impact injury within the past 3 months", "Fracture within the past 3 months", "Orthopedic, spine, joint, or muscle-related surgery within the past 3 months", "Past sports injury that is now mostly stable", "History of car accident, fall, or major trauma", "No clear history of sports injury or trauma", "Not sure"]}, {"hipaa_name": "does_the_pain_affect_your_daily_function", "mod_type": "checkbox", "label": "Does the pain affect your daily function?", "required": false, "options": ["Not much impact", "Affects sleep", "Affects walking", "Affects going up or down stairs", "Affects bending, turning, sitting for long periods, or standing for long periods", "Affects lifting the arm, dressing, washing hair, or holding objects", "Affects work or household activities", "I have reduced physical activity because of pain", "I frequently need pain medications", "I need a cane, brace, support device, or help from another person"]}, {"hipaa_name": "which_descriptions_best_match_the_quality_of_your_pain", "mod_type": "checkbox", "label": "Which descriptions best match the quality of your pain?", "required": false, "options": ["Aching pain", "Tight or distending pain", "Stabbing pain", "Burning pain", "Numbness", "Electric-shock-like pain", "Stiffness", "Heavy sensation", "Cold pain, worse with cold exposure", "Worse after activity", "Worse after rest", "Worse at night", "Worse after emotional stress, anger, or tension"]}, {"hipaa_name": "how_long_has_this_pain_been_present", "mod_type": "choice", "label": "How long has this pain been present?", "required": false, "options": ["Less than 1 week", "1\u20134 weeks", "1\u20133 months", "3\u20136 months", "More than 6 months", "Recurrent for many years", "Not sure"]}, {"hipaa_name": "what_is_the_severity_of_your_main_pain_area", "mod_type": "text", "label": "What is the severity of your main pain area?", "required": false, "description": "If 0 means no pain and 10 means extreme pain"}, {"hipaa_name": "have_you_ever_been_diagnosed_by_a_physician_with_any_of_the_following_conditions", "mod_type": "checkbox", "label": "Have you ever been diagnosed by a physician with any of the following conditions?", "required": false, "options": ["Diabetes", "Prediabetes / impaired glucose tolerance", "High blood pressure / hypertension", "High cholesterol or high triglycerides", "Coronary artery disease / history of heart attack", "Stroke / TIA history", "Chronic kidney disease / CKD", "Abnormal urine protein or abnormal uACR", "Fatty liver", "Vascular Plaque / Atherosclerosis / Vascular Narrowing", "Gout", "Gallstones", "Kidney stones", "No confirmed diagnosis from the above"]}, {"hipaa_name": "infection_liver_immune_and_other_conditions", "mod_type": "checkbox", "label": "Infection, Liver, Immune, and Other Conditions", "required": false, "options": ["Hepatitis B", "Hepatitis C", "Cirrhosis", "Autoimmune disease", "History of cancer", "Organ transplant history", "Thyroid disease", "No confirmed diagnosis from the above"]}, {"hipaa_name": "are_you_currently_using_any_of_the_following_medications_injections_or_longterm_treatments", "mod_type": "checkbox", "label": "Are you currently using any of the following medications, injections, or long-term treatments?", "required": false, "options": ["Steroid medications, such as prednisone, methylprednisolone, dexamethasone, or similar medications", "Immunosuppressants, biologics, or JAK inhibitors, such as cyclosporine, tacrolimus, adalimumab, dupilumab, tofacitinib, or similar medications", "Blood thinners / anticoagulants, such as warfarin, rivaroxaban, apixaban, dabigatran, or similar medications", "Antiplatelet medications, such as aspirin, clopidogrel, or similar medications", "Diabetes medications, such as metformin, SGLT2 inhibitors, GLP-1 medications, sulfonylureas, or similar medications", "Insulin", "Blood pressure medications, such as calcium channel blockers, ACE inhibitors, ARBs, diuretics, beta blockers, or similar medications", "Cholesterol or lipid medications, such as statins, fenofibrate, ezetimibe, PCSK9 inhibitors, or similar medications", "Psychiatric, sleep, or sedative medications, such as anti-anxiety medications, antidepressants, sleep medications, or sedatives", "Pain medications or anti-inflammatory medications, such as ibuprofen, naproxen, celecoxib, opioid pain medications, or similar medications", "Thyroid medications", "Long-term supplements, herbal products, traditional medicine products, or dietary supplements", "I am not currently using any of the above long-term medications or treatments", "Not sure"]}, {"hipaa_name": "if_you_selected_any_medication_or_supplement_above_please_list_the_name_dose_frequency_and_reason_for_use_if_known", "mod_type": "text", "label": "If you selected any medication or supplement above, please list the name, dose, frequency, and reason for use if known.", "required": false, "description": "Please include prescription medications, over-the-counter medications, injections, topical medications, supplements, herbal products, and traditional medicine products. Example: Metformin 500 mg, twice daily, for diabetes.", "max_length": 200}, {"hipaa_name": "file_upload", "mod_type": "file", "label": "File Upload", "required": false, "description": "Please upload your most recent report as a PDF, screenshot, scanned report, or clear photo. Maximum file size: 50 MB per file.", "max_length": 8}, {"hipaa_name": "file_upload", "mod_type": "file", "label": "File Upload", "required": false, "description": "Please upload your most recent report as a PDF, screenshot, scanned report, or clear photo. Maximum file size: 50 MB per file.", "max_length": 8}, {"hipaa_name": "file_upload", "mod_type": "file", "label": "File Upload", "required": false, "description": "Please upload your most recent report as a PDF, screenshot, scanned report, or clear photo. Maximum file size: 50 MB per file.", "max_length": 8}, {"hipaa_name": "have_you_ever_been_diagnosed_by_a_physician_or_told_that_you_may_have_any_of_the_following", "mod_type": "checkbox", "label": "Have you ever been diagnosed by a physician or told that you may have any of the following?", "required": false, "options": ["Hepatitis B carrier status / positive HBsAg", "Hepatitis B with positive viral markers, such as HBeAg or HBV DNA elevation", "Hepatitis C / HCV positive or history of hepatitis C", "High-risk HPV positivity", "Persistent HPV positivity for more than 1 year", "Abnormal Pap smear / TCT, such as ASC-US, LSIL, or HSIL", "Cervical intraepithelial neoplasia, such as CIN1, CIN2, or CIN3", "History of tuberculosis infection or active tuberculosis", "Recurrent infections, such as recurrent urinary tract infections, vaginitis, skin infections, or respiratory infections"]}, {"hipaa_name": "autoimmune_immune_inflammatory_or_endocrine_immune_conditions", "mod_type": "checkbox", "label": "Autoimmune, Immune-Inflammatory, or Endocrine-Immune Conditions", "required": false, "options": ["Hashimoto\u2019s thyroiditis / positive TPOAb or TgAb", "Graves\u2019 disease / autoimmune hyperthyroidism", "Systemic lupus erythematosus / SLE", "Rheumatoid arthritis", "Ankylosing spondylitis", "Psoriasis or psoriatic arthritis", "Inflammatory bowel disease, such as Crohn\u2019s disease or ulcerative colitis", "Sj\u00f6gren\u2019s syndrome", "Vasculitis", "Multiple sclerosis or another neuroimmune condition", "None of the above"]}, {"hipaa_name": "are_any_of_these_infection_immune_inflammatory_or_endocrineimmune_conditions_currently_active_or_unstable", "mod_type": "choice", "label": "Are any of these infection, immune, inflammatory, or endocrine-immune conditions currently active or unstable?", "required": false, "options": ["No, the condition is currently stable or not active", "Yes, symptoms or lab markers have fluctuated noticeably within the past 1\u20133 months", "Yes, I am currently in a flare or my physician has said the condition is active", "Not sure"]}, {"hipaa_name": "please_upload_any_related_specialist_reports_or_laboratory_results_if_available", "mod_type": "file", "label": "Please upload any related specialist reports or laboratory results if available.", "required": false, "description": "You may upload reports related to hepatitis B, hepatitis C, HPV, Pap smear / TCT, colposcopy, cervical biopsy, thyroid function, thyroid antibodies, thyroid ultrasound, autoimmune antibodies, inflammatory markers, rheumatology evaluation, infectious disease evaluation, or recent specialist notes.Reports from the past 3 months are preferred. Accepted examples include PDF reports, screenshots, scanned reports, or clear photos of the report. Maximum size: 50MB per file.", "max_length": 10}, {"hipaa_name": "upload_baseline_reports", "mod_type": "file", "label": "Upload Baseline Reports", "required": false, "max_length": 15}, {"hipaa_name": "is_there_anything_else_you_would_like_the_meta_flow_review_team_to_know", "mod_type": "text", "label": "Is there anything else you would like the MetaFlow review team to know?", "required": false, "description": "You may add any important context about your health history, reports, medications, symptoms, or participation readiness.", "max_length": 300}]
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