Medical Form

(*) Required

Medical Form

Patient Information Medications Details Review

First Name (*)

Middle Name

Last Name (*)

Email (*)

Gender (*)

Male

Female

Date of Birth (*)

Height (*)

Weight (*)

Home Phone

Cell Phone (*)

Work Phone

Marital Status

Address

Address 2 (apt., floor)

City

State (*)

Zip (*)

Occupation

Referred by

In Case of Emergency

Name of local friend or relative

Relationship

Home Phone

Work Phone

Allergies

Have you ever had hormone therapy? (*)

Yes

No

What are your top three goals for starting Hormone Replacement Therapy? (*)

Medications

Are you currently taking any other than those for Hormone/Testosterone Therapy? if so, list each medication, dosage and frequency below

Additional Information

This Section is for Men Only

Have you had a prostate exam? (*)

Yes

No

Have you had a recent wellness/physical exam? (*)

Yes

No

Have you been diagnosed with prostate cancer? (*)

Yes

No

Have you been diagnosed with breast cancer? (*)

Yes

No

Have you had prostate enlargement? (*)

Yes

No

Have you had any form of cancer? (*)

Yes

No

Do any of the following apply?

Have you noticed a decrease in your sex drive? (*)

Yes

No

Have you noticed a decrease in energy levels? (*)

Yes

No

Do you feel weaker or have less stamina? (*)

Yes

No

Do you feel tired all the time? (*)

Yes

No

Have you noticed decreased work performance? *

Yes

No

Are you more lethargic after dinner? (*)

Yes

No

Are your erections less hard? (*)

Yes

No

Are you prone to sadness or anger? (*)

Yes

No

Has your height diminished? (*)

Yes

No

Are you suffering from less vitality? (*)

Yes

No

Additional Information

Gynecology Information

Have you had a recent wellness/physical exam?

Yes

No

Have you had any of the following types of cancer?

Ovarian

Yes

Uterine

Yes

Breast Cancer or Suspicion

Yes

Cervical

Yes

Any form of cancer

Yes

Are you Currently Pregnant? (*)

Yes

No

Do you plan to have more children? (*)

Yes

No

Are you Currently Breastfeeding? (*)

Yes

No

Are you currently sexually active? (*)

Yes

No

Hot flashes (*)

Yes

No

Mood swings (*)

Yes

No

Vaginal dryness (*)

Yes

No

Headache / Fatigue (*)

Yes

No

Painful intercourse (*)

Yes

No

Short term memory or memory concerns (*)

Yes

No

Decreased sex drive (*)

Yes

No

Dry skin (*)

Yes

No

Water retention (*)

Yes

No

Bone mineral loss (Osteoporosis) (*)

Yes

No

Fat, especially hips, thighs, and abdomen (*)

Yes

No

Diffuse Body Pain/Aches (*)

Yes

No

Sleep disturbances (*)

Yes

No

Date of last period

Date of last period How many days does your period last?

Do you have heavy cycles? If Yes, please explain.

Yes

No

Do you have regular cycles? If no, please explain.

Yes

No

Do you take any medications or supplements to address any issues with menstruation?

Have you have had a mammogram, when was your last one?

Yes

No

What were your results?

Review

Head Trauma

Yes

Cancer of any type

Yes

Heart disease or any heart related issues

Yes

HIV or related disease

Yes

High blood pressure

Yes

Immune deficiency of any type

Yes

Strokes

Yes

Skin disorders

Yes

Poor Circulation

Yes

Muscular or bone disorders

Yes

Edema or Swelling

Yes

Arthritis or autoimmune disorders

Yes

High Cholesterol

Yes

Disorder of the nervous system

Yes

Hormonal imbalance of any type

Yes

Seizure disorder

Yes

Sleep Apnea

Yes

Psychiatric disorders

Yes

Lung disorders

Yes

Psychiatric Hospitalizations

Yes

Clotting disorders

Yes

Depression

Yes

Digestive disorders

Yes

Vision disorders

Yes

Liver disorders

Yes

Hearing disorders

Yes

Hepatitis of any type

Yes

Upper respiratory, sinus disorders

Yes

Diabetes

Yes

Excessive snoring

Yes

Kidney disorders

Yes

Contagious condition

Yes

Bladder disorders

Yes

Illnesses contracted while abroad

Yes

Testicular or genital problems

Yes

Life threatening conditions

Yes

Physical defect or deformity

Yes

Genetic Disorders

Yes

Additional Information

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