If requested, please use this onboarding form to engage with me.

This questionnaire contains medically sensitive information which I need to adequately assess risks and may take 5-15 minutes to complete. All information collected is managed under my Privacy Policy.

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Name *

Email *

Enquiry *

• Disease model / protocol orientation
• Patient advocacy
• Other

Data Handling / de-identification *

• I will provide any health information de-identified by default (no full name, DOB, address, phone, ID numbers, face photos), unless strictly necessary.

Scope and responsibility *

• I understand Joshua Leisk is not a registered health practitioner in NSW, Australia. This engagement is for educational and research-translation ONLY, it is not for diagnosis or treatment. Any views shared or suggestions (including diet or supplements) are discussion prompts for me and the treating clinician, especially where they may interact with existing conditions or treatments. I agree not to start, stop, or change medications or other treatments based solely on this engagement, and to seek urgent care via emergency services for red-flag symptoms (e.g., chest pain, severe allergic reaction, new neurological deficit, suicidal intent). This service is not equipped for emergencies.

Privacy policy *

• I consent to the collection, use, storage, and disclosure of the information I provide (including health information if I choose to provide it) in accordance with the Privacy Policy. I understand third-party platforms and cloud storage may be used and may involve overseas processing.

Privacy policy can be found here – https://joshualeisk.com/privacy-policy/ or click the link in the footer of the website.

Clinician/Organisation name (optional)

Clinician/Organisation email (optional)

Optional permissions

• You may contact the nominated clinician/organisation about this matter.
• You may use de-identified excerpts to improve educational materials (no identifiers).

Deletion requests: email privacy [at] joshualeisk.com and reasonable steps will be taken to delete or de-identify information where practicable.

Client name (where you are the legal guardian and communicating on behalf):

Client age (or age band) – and if under 18 – confirmation that I am the legal guardian: *

Biological sex at birth: *

Full current list (or none) for any/all prescription meds, OTC meds, hormones, and/or supplements/herbs, plus dosing schedule and intended purpose: *

Any history of bleeding disorder, easy bruising/bleeds, planned surgery/dental procedure in next 30 days, antiplatelet / anticoagulant use, eg. aspirin, clopidogrel (details, or none)? *

Any history of arrhythmias, prolonged QT, heart failure, uncontrolled hypertension, POTS (or none)? *

Any history of diabetes/hypoglycaemia (or none)? *

Any current immunosuppressants/biologics, history of transplant, active cancer therapy (or none)? *

I am pregnant/breastfeeding, or trying to become pregnant (yes/no): *

Any history of kidney/liver disease (or none)? *

of are: 30

Any history of seizures or loss of consciousness (or none)? *

Any history of low/high blood pressure (details or none)? *

Any history of trauma, PTSD-like hyperarousal, panic, severe anxiety or stimulant sensitivity (or none / prefer not to say)? *

Any history of severe adverse reactions, prior anaphylaxis, angioedema, serotonin syndrome, rhabdomyolysis (or none)? *

Anything your clinician has told you to avoid (foods/supplements/activities) and why (or none): *

I have known allergies for (or none): *

I have known tolerance issues to (or none): *

Any history of bipolar/mania/psychosis/OCD/depression/anhedonia (or none)? *

Any history of thyroid disease / thyroid meds and/or targeted supplements (or none)? *

Any history of kidney stones / hyperoxaluria (or none)? *

Any history of haemochromatosis / iron overload / beta-thalassemia (or none)?

Any history of G6PD deficiency (or none)? *

Any surgical history, including organ / tissue removal, eg. adenoids, teeth, gall bladder, etc (or none)? *

Any history of structural issues, neck or spinal injuries, thoracic outlet syndrome (or none)? *

Any history of other medical issue(s) a practitioner would reasonably need to be aware of (or none)? *

Current dietary strategy (standard mixed, low carb, keto, etc): *

My current issues (and when they started) are: *

Confirmation of terms – please type I ACCEPT into the field below: *

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