Form WEF-INT-002 · Member Intake

Blood panel data.

If you've already pulled labs in the last twelve months, share what's relevant. Submitted to Dr. Swet Chaudhari, MD (Chief Medical Officer) and Dana Kantara, MHS (Cellular Health Expert) for review — they translate the signal into a programming brief and route it to your coach. WEF is not your prescriber; we use this to coach better.

Type in only the markers you have. Leave the rest blank. Use your lab's reference units — we'll normalize. If you'd rather upload a PDF of your full panel, email it to hello@mywellnesscorporation.com after submitting this form so it stays attached to your file.

Or download the PDF version →

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Member identification

Full name *

Date of birth

Member ID (if known)

Email *

Phone

Sex assigned at birth

Gender identity (if different)

Draw details

Date drawn

Lab / source

Fasting?

Time of draw

Hours since last meal

Cycle phase (if applicable)

Recent illness or stressor in last 7 days

Complete blood count (CBC)

Only fill in what you have. Reference range comes off your lab report.

MarkerValueUnits / range

White blood cells (WBC)

Red blood cells (RBC)

Hemoglobin

Hematocrit

Platelets

MCV / MCH / MCHC (if flagged)

Comprehensive metabolic panel (CMP)

MarkerValueUnits / range

Glucose (fasting)

BUN

Creatinine

eGFR

Sodium

Potassium

Calcium

Albumin / total protein

ALT

AST

Alkaline phosphatase

Bilirubin (total)

Lipid panel

MarkerValueUnits / range

Total cholesterol

LDL

HDL

Triglycerides

ApoB (if measured)

Lp(a) (if measured)

Endocrine · thyroid · hormones

MarkerValueUnits / range

TSH

Free T3

Free T4

Reverse T3 (if measured)

Cortisol (AM)

Total testosterone

Free testosterone

SHBG

DHEA-S

Estradiol

Progesterone

FSH / LH

Insulin (fasting)

HbA1c

HOMA-IR (calculated)

Performance · longevity markers

MarkerValueUnits / range

hs-CRP

Homocysteine

Vitamin D (25-OH)

Vitamin B12

Folate

Ferritin

Iron / TIBC / saturation

Magnesium (RBC if available)

Omega-3 index

Uric acid

CK (creatine kinase)

GGT

IGF-1 (if measured)

Other markers worth surfacing

Anything else flagged on your report (in / out of range)

Symptoms · concerns

What is the lab story you're trying to solve? Three sentences is enough.

What you want Dr. Chaudhari + Dana to focus on

Current medications + supplements

Especially anything that moves these markers — statins, thyroid Rx, HRT, peptides, iron, B-vitamin stacks.

Family history (relevant only)

Notes on family history (optional)

Anything else

Additional notes for Dr. Chaudhari / Dana

By submitting, I authorize Wellness Elite Fitness to share this lab data with Dr. Swet Chaudhari, MD and Dana Kantara, MHS for review, and to forward the resulting programming notes to my assigned coach. I understand WEF is a wellness facility, not a medical provider, and any clinical follow-up will be referred back to my physician or to Dr. Chaudhari's separate practice. WEF does not diagnose, treat, or prescribe. See privacy policy.