Health History and Waiver

Health History and Waiver
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
What is your gender?*
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Email Address*
example@example.com
Contact Number*
Check the medical conditions conditions that apply to you:

Low testosterone (hypogonadal)MenopausePerimenopauseHypertensionDyslipidemiaHypertriglyceridemiaType 1 Diabetes MellitusType 2 Diabetes MellitusHypothyroidismHyperthyroidismGERDBPHProstate CancerAtrial FibrillationMyocardial InfarctionDeep Vein ThrombosisPulmonary EmbolismAnxietyDepressionBreast CancerUterine CancerCrohn's DiseaseUlcerative ColitisPCOSOther
Surgical Hx
Hospitalizations
Check the symptoms that you' re currently experiencing:

Low energy or fatigueDecreased motivationIncreased body fatWeight GainDecreased exercise toleranceDecreased enduranceAching or stiff jointIncreased joint painMuscle aches/painsDecreased sense of well-beingIncreased stressSad and/or grumpyThinning or dry skinFalling asleep after dinnerDecreased ability to play sportsForgetful, poor memoryDecreased libido or sexual desireErections less strongDecreased spontaneous early AM erectionsBrain fog or memory lossHot FlashesRestless sleepMoody or irritableDifficulty concentratingHeavy periodsIrregular periodsVaginal drynessOther
What aspect of your health are you looking to improve or what are you most interested in?
List prescribed medications and supplements
Are you allergic to any medications?*
List allergies to medications
Tobacco or Marijuana use
Are you sexually active?
Are you currently trying to get pregnant/conceive?
How many days of exercise do you get per week?
How many alcohol beverages do you consume per week?
How many caffeinated beverages do you consume per week?
How many hours of sleep do you get per night?
Describe your diet. Do you follow any specific dietary guidelines?
Please upload your driver's license, recent labs, and other health documents*
Consent

By signing below, I agree to complete and submit this health history accurately, truthfully, and completely. I acknowledge that failure to provide truthful, accurate, and complete information on this health history could result in my receiving inappropriate or ineffective treatment. I also understand that the information submitted on this Health History will be held confidential and only disclosed or used in accordance with the Health Insurance Portability and Accountability Act and other applicable state and federal laws. I understand that hormone and peptide optimization therapy is an off-label use of FDA-approved medications. Potential risks include but are not limited to testicular atrophy, infertility, erythrocytosis (high levels of red blood cells), blood clots, heart attack, stroke, transference to other topical treatments, heart arrhythmias, hormone-related cancers, among others. These risks have been adequately explained to me, and I understand the benefits of treatment are thought to outweigh these risks and consent to treatment. Any information given to me by anyone other than trained medical staff should not be treated as a treatment plan or medical advice. If hormone optimization is deemed appropriate by my medical provider, I hereby authorize Starwalt Health and Wellness to automatically fill and ship medications prescribed to me – charging my credit card on file. I understand I can cancel at any time, in writing, to discontinue the service.
Signature*

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