Patient Enrollment and Update Form

Patient Enrollment / Update Form

Dr. Lauren Bramley BSc., MD., CCFPC, MSc. Endocrinology, Diabetes & Metabolism.
Name

First NameLast Name
Date of Birth

MonthDayYear
Sex
Contact Number:
E-mail
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
In case of emergency
Emergency Contact:

First NameLast Name
Relationship
Contact Number
Allergies to Medications, Supplements Other Allergens
Weight (pounds)
Height (inches)
Preferred Weight (If Different)
Please list any Important Medical History: For example: diabetes, cancer, coronary heart disease , high blood pressure, ICU or hospital admission, drug reaction
Please list any known Important Medical History of your biological family: For example: diabetes, cancer, coronary heart disease, stroke, dementia
Taking any supplements, currently?

YesNo
If yes, please list here, ideally with brand and dose
Taking any prescribed medications ?

YesNo
If Yes Please List Here
Please list your top 10 concerns regarding your health and well being.
I suspect or have been told I may have:

Hormonal ImbalanceThyroid DisorderMetabolic DisorderMitochondrial DisorderHeavy Metal or Mold ToxicityFoodAllergy or IntoleranceSIBO, Leaky Gut, CandidiasisInsulin ResistanceDiabetes or Pre-DiabetesCoronary Artery DiseaseHigh Blood PressureSleep Disorder
Have you had your Biological Age Tested ? ex Truage Trudiagnostic ? If so when and what was your result ?
Have you ever had Genetic Testing ? If so which one ?

23andmeSelf DecodeSellect SNPsOther
Have You Had a Saliva, Urine or Blood Hormone Panel in the Past 12 months ? Please upload your result below or email to lauren.bramley@laurenbramleymd.com prior to your consultation.

YesNo
Have you had other lab tests done in the past 12 months. Please upload your result below or email to lauren.bramley@laurenbramleymd.com prior to your consultation.

YesNo
I would like to learn more about:

Peptide TherapyWeight ManagementBioidenltical Hormone TherapyAge ReversalTruage Trudiagnostic Biological Age TestingThe Better With Age ClubRegenera Activa Hair TreatmentHeavy Metal Testing and TreatmentMold Toxicity and TreatmentGenomicsImproving my AppearanceImproving my EnergyImproving my Cognitive FunctionSports PerformanceProdrome Sciences Plasmologen Testing & Treatment for Preventing Cognitive DeclineImproving my Mood, Joy In LivingImproving My NutritionAesthetic Medicine: Botox/Neuceiva Hyaluronic Acid FillersImproving my Love LifeOther
Please let us know your preferred time for a consultation on Pacific Time : example: early am, weekdays, weekends, evening etc..
Please List Your Pharmacy Preference Name , address and fax. If you use both a compound pharmacy and a regular pharmacy please list both.
Please list your Family Doctor, GP, Primary Care Physician Name and Location Here:
My current feeling about reversing my biological age is:

I am open to a few things, but really dont like taking too many things. I prefer to keep it simple.I am middle of the road, I am more open to trying new things, but prefer to take it step by step.Bring it on. I like to learn about and try lots of new therapeutics in the field of age reversal.Not sure.
Please upload any previous lab results.

Cancelof
Thank you for completing this form. Please choose a first or follow up zoom consultation with Dr Lauren Bramley form the calendly link below. You can also request an information call about The Better With Age Club.

To Book a Online Consultation For Existing Patients:
https://www.thebetterwithageclub.com/booking-calendar/virtual-consultation-for-non-members?utm_medium=page_links

To Book a Online Consultation For New Patients:
https://www.thebetterwithageclub.com/booking-calendar/new-patient-virtual-consultation?utm_medium=page_links
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Patient Enrollment / Update Form