Sovereign

Section 1 — Personal details

Full legal name

Date of birth

Nationality

Passport / ID number

Bangkok address / residence

Emergency contact name

Emergency contact phone

Preferred communication channel

Primary language of communication

EnglishThaiArabicFrenchGermanOther

Section 2 — Health baseline

Diagnosed medical conditions — current or historical

Current medications and supplements — name, dose, frequency

Date of last comprehensive bloodwork

Name of primary physician — if any

Insurance provider

Policy number

Known allergies or sensitivities

No known allergiesDrug allergiesLatexFood intolerancesIV / infusion reactionsOther

Blood panel in the past year?

Yes — I have a copyYes — no results availableNo / first time

Previous health interventions — select all that apply

Hormone panel / TRTStem cell / exosome therapyPlasma exchangeIV nutrient therapyPeptide protocolsFunctional medicineCGM / wearable trackingGut microbiome testingNone of the above

Section 3 — Lifestyle & performance baseline

Sleep quality — 1 is very poor, 10 is excellent

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Average sleep duration per night

Under 5 hrs5–6 hrs6–7 hrs7–8 hrs8+ hrs

Daily energy levels — 1 is chronically fatigued, 10 is consistently high

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Stress / cortisol load — 1 is very low, 10 is extremely high

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Exercise frequency

NoneLess than 2x / week3–4x / week5+ / weekDaily structured training

Primary fitness focus

Strength trainingCardio / enduranceMixed / functionalYoga / mobilityNone currently

Dietary pattern

Standard / mixedLow-carb / ketoPlant-basedIntermittent fastingPrecision / trackedOther

Preferred appointment format

In-clinic visitsHome / hotel visitsVirtual consultationsFlexible

Section 4 — Goals & priorities

Primary goals — select all that apply

Lifespan extension / longevityCognitive performancePhysical performance & strengthHormonal optimisationAesthetic / body compositionChronic disease managementMental health & stress resilienceSexual health & vitalityPreventive cancer screeningGut health & microbiomeAnti-ageing skin & aestheticsWeight management

Describe your single most important health goal in your own words

What would a successful first year with Zenify look like for you?

Anything specific you want us to know before your onboarding call
[textarea onboard

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Occasional updates on clinical developments, provider standards, and what Zenify members should know about navigating healthcare in Thailand. No marketing. No frequency commitments. Useful, or nothing at all.

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