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Medical History Questionnaire
Which medications would you like to talk to the physician about? (Check all that apply)
*
Acarbose
Atorvastatin (generic for Lipitor)
Birth Control (Lo Loestrin FE, Junel FE, Nuvaring)
Glutatione (GSH) Injections
Lidocaine/Prilocaine Cream
Metformin
NAD+ Injections
Rapamycin (sirolimus)
Sertaline
Tadalafil (generic for Cialis)
Telmisartan (generic for Micardis)
Tretinoin (generic for Retin-A)
Valacyclovir (generic for Valtrex)
Vitamin B-12 Injections
Wegovy
Other
Full Name
*
First Name
Last Name
Phone Number
*
What is your Gender?
*
Male
Female
Other
Prefer not to disclose
Do you have allergies to any of the following? (Check all that apply)
*
Amoxicillin/Penicillin
Aspirin
Codeine
Latex
Sulfa Drugs
None
Other
What is your height in feet and inches?
*
What is your weight in pounds?
*
How often do you exercise?
*
Please Select
Never
Less than once a week
Once a week
Two or three times a week
More or less every day
Which of the following best applies to your reproductive status?
*
Please Select
I am not currently pregnant or breastfeeding.
I am currently pregnant or breastfeeding.
I plan to become pregnant or breastfeed within the next 6 months.
I am currently going through menopause.
I had a hysterectomy or am post-menopausal.
I am a male.
Do you have any of the following medical conditions? (Check all that apply)
*
Anxiety or Depression
Asthma or COPD
Cancer
Diabetes
Heart Disease
HIV or AIDS
Hypertension (high blood pressure)
Irregular Heart Beat
Kidney Disease
Thyroid Condition
Vascular Disease (Stroke, Blood Clots, etc.)
Other
No Medical Problems/Conditions
Have you ever been told that your kidneys are not working properly?
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Yes
No
Have you ever been told that your liver is not working properly?
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Yes
No
Have you ever been told that your heart is not working properly?
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Yes
No
Do you use or do you have a history of using tobacco?
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Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Have you had any of the following surgeries? (Check all that apply)
*
Appendix Surgery
Back or Neck Surgery
Gallbladder
Heart Surgery or Stenting
Hysterectomy (females only)
Prostate Surgery (males only)
No Past Surgeries
Other
In the past 12 months, have you experienced any of the following?
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Never
Sometimes
Regularly
Often
Always
Diarrhea
Headache
Sudden High Fever
Coughing
Skin Problems (e.g. eczema, acne)
Muscle and Joint Pain
Common Cold
Do any of your immediate family members have a history of the following conditions? (Check all that apply)
*
Cancer
Dementia
Diabetes
Heart Disease
High Cholesterol
Hypertension (high blood pressure)
None of these
Please list any medications you are currently taking or type "None" if not taking any medications.
*
Do you have a primary care provider?
*
Yes
No
Have you had a general health check-up or routine physical in the past 3 years?
*
Yes
No
Is there anything you would like the physician to know about your health?
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Medication Specific Questionnaire
Why would you like to start taking Wegovy? (Check all that apply)
*
Lose weight
Regulate appetite and caloric intake
Lower blood pressure and cholesterol
Lower blood sugar levels
In the past 12 months have you experienced any of the following? (Check all that apply)
*
Anemia
Blurred vision
Decreased mental acuity or reasoning
Mood swings
Nerve pain
Weakness or fatigue
What best describes your diet?
*
Keto
Paleo
Vegan
Vegetarian
No specific diet
Other
Does you or family have a history of any of the following conditions?
*
Pancreatitis
Thyroid Cancer
MEN2 (multiple endrocrine neoplasia type 2)
None of the Above
Have you ever been hospitalized for a mood-related disorder such as bipolar disorder, depression, or schizophrenia?
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Yes
No
Do you have any history of suicidal thoughts or ideation?
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Yes
No
Have you tried any weight loss programs in the past?
*
Yes
No
Are you comfortable with giving yourself subcutaneous injections?
*
Yes
No
I understand that I will be titrated on Wegovy as required by the FDA.
*
Yes
Why would you like to start taking Metformin? (Check all that apply)
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Lose weight
Lower blood sugar levels
Reduce the risk of dementia and cognitive decline
Reduce the risk of colon and pancreatic cancer
Reduce the risk of macrovascular disease
Improve longevity and anti-aging
Have you ever taken Metformin?
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Yes
No
Are you prone to hypoglycemia (low blood sugar)?
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Yes
No
Have you ever had low Vitamin B-12?
*
Yes
No
Why would you like to start taking Acarbose? (Check all that apply)
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Lose weight
Reduce post-mealtime glucose spikes
Maintain stable blood sugar levels
Have you ever taken Acarbose?
*
Yes
No
Are you prone to hypoglycemia (low blood sugar)?
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Yes
No
Do you have a history of any of the following conditions?
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Eating Disorder (e.g. Anorexia, Bulimia)
Gastrointestinal Disorder (e.g/. Crohn's Disease, Celiac's Disease, Irritable Bowel Syndrome)
Liver Cirrhosis
None of the Above
How often does your weight affect your mood in a negative way?
Every day
Most days
Some days
Not at all
Why would you like to start taking Atorvastatin? (Check all that apply)
*
Lower cholesterol and LDL levels
Improve HDL levels
Reduce the risk of strokes, heart attacks, and arterial plaque build-up
Does any of the following apply to you?
*
Heavy alcohol consumption (8 or more drinks/week for women, 15 or more drinks/week for men)
Gastrointestinal Disorder (e.g/. Crohn's Disease, Celiac's Disease, Irritable Bowel Syndrome)
None of the Above
Do you have any of the following conditions? (Check all that apply)
*
High blood pressure
Heart attack/angina/mini-stroke/stroke
Kidney disease
Liver disease
Myopathy
Uncontrolled hypothyroidism
None of the Above
Does you or your family have a family history of myopathy (muscle weakness or damage)? (Check all that apply)
*
Mother
Father
Brother
Sister
Grandparent
Other
None of the Above
Are you currently taking or have you previously taken any of the following medications?
*
Beta-blockers (e.g. atenolol, propranolol)
Diltiazem and/or diuretics (e.g. hydrocholorothiazide)
Niacin-laropiprant
Verapamil
None of the Above
Have you completed any blood work for your lipid panels in that past year?
*
Yes
No
OPTIONAL: If available, please upload your most recent blood work for your lipid panels.
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Why would you like to start taking Glutathione (GSH) injections? (Check all that apply)
*
Reduce cellular degeneration from aging and stress
Improve energy, mental clarity, and focus
Reduce free radical damage from degenerative disease
Reduce chronic inflammation
Support a healthy immune system
Remove toxins and protect cells from damage
Have you ever taken Glutathione?
*
Yes
No
Are you comfortable with giving yourself subcutaneous injections?
*
Yes
No
Why would you like to start taking NAD+ injections? (Check all that apply)
*
Improve energy levels, mental clarity, and mood
Reduce cravings and fatigue
Improve post-workout recovery
Get a better quality of sleep
DNA repair
Decrease skin damage
Weight loss
Improve heart function
Improve immune system
Are you comfortable with giving yourself subcutaneous injections?
*
Yes
No
Have you ever taken NAD+?
*
Yes
No
Why would you like to start taking Vitamin B-12 injections? (Check all that apply)
*
Improve and regulates mood
Improve sleep quality
Reduce fatigue and promotes natural energy
Improved cognitive performance
For healthy skin and nails
Boost metabolic function
Reduce risk of cardiovascular diseases
Improve bone density and skeletal health
Are you comfortable with giving yourself intramuscular injections?
*
Yes
No
Have you ever taken Vitamin B-12 supplementation?
*
Yes
No
In the past 12 months have you experienced any of the following? (Check all that apply)
*
Anemia
Blurred vision
Decreased mental acuity or reasoning
Mood swings
Nerve pain
Weakness or fatigue
What best describes your diet?
*
Keto
Paleo
Vegan
Vegetarian
No specific diet
Other
Have you ever taken heartburn medications (e.g. Prilosec, Pepcid, Tums) for an extended period of time (either prescription or OTC)?
*
Yes
No
Why would you like to start taking Tretinoin? (Check all that apply)
*
Reduce fine lines and wrinkles
Improve collagen production
Treat adult acne
Repair sun damage
Prevent aging skin
Correct discoloration or hyperpigmentation
Boost skin firmness
How would you describe your facial skin type?
*
Very Dry
Somewhat Dry
Combination of Dry and Oily
Somewhat Oily
Very Oily
How does your face react to skin care products?
*
I am very sensitive to skin care products
I am somewhat sensitive to skin care products
I have no sensitivit issues to skin care products
Are you currently using any of the following skin care products? (Check all that apply)
*
Benzoyl peroxide
Resorcinol
Salicylic acid
Sulfur
None of the above
Other
Do you have or have had a history of any of the following skin conditions? (Check all that apply)
*
Cold Sores
Eczema
Melanoma (or other skin cancer)
Psoriasis
Rosacea
None of the above
Other
Please describe your current skin care regimen that you do on a regular basis
Have you ever taken Tretinoin
*
Yes
No
OPTIONAL: If available, please provide a picture of your face to better understand any skin concerns you may have.
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By continuing, you acknowledge and understand to read the information that is supplied with your prescription. You also agree to contact Forever Young Pharmacy if there are any side effects and you understand Forever Young Pharmacy does not screen for any skin cancers, and does not replace the need for routine, in-person care with a dermatologist.
*
I acknowledge and understand
Why would you like to start taking Tadalafil (generic for Cialis)? (Check all that apply)
*
Improve the quality of erections
Reduce an enlarged prostate
Reduce urinary symptoms and high blood pressure
Improve blood flow to the kidneys and reduce systemic inflammation
Help with premature ejaculation
Improve intimacy with a partner
Longevity benefits
Have you ever taken any of the following for erectile dysfunction? (Check all that apply)
*
Sildenafil (Viagra)
Tadalafil (Cialis)
Vardenafil (Levitra)
Avanafil (Stendra)
Testosterone support / replacement
Penile injections
Penile surgery or use of pumps
None of the above
How would you describe your current sexual performance? (Check all that apply)
*
Difficulty forming an erection
Difficulty maintaining an erection
Ejaculating too early (premature ejaculation)
Low libido
Not sexually active
None of the above
Other
Have you ever been prescribed or used nitrates? Examples of common nitrates include: Nitroglycerin (Nitro-Dur, Nitrolingual or Nitrostat), Isosorbide (Dilatrate or Isordil), Nitroprusside (Nitropress) or Amyl nitrite ("poppers”).
*
Yes
No
When was the last time you had a morning erection?
*
Please Select
Less than 3 months ago
Between 3 to 6 months ago
Over 6 months ago
I've never had a morning erection
When was the last time you had what you consider "normal" sexual function?
*
Please Select
Less than 3 months ago
Between 3 to 6 months ago
Over 6 months ago
Never
When did you last have your blood pressure taken?
*
Please Select
Less than 1 month ago
Between 1 to 3 months ago
Between 3 to 6 months ago
Over 6 months ago
What was your most recent systolic blood pressure reading (the top number)?
*
Please Select
Between 80 - 100
Between 101 - 159
Between 160 - 200+
I don't know
What was your most recent diastolic blood pressure reading (the bottom number)?
*
Please Select
Between 50 - 60
Between 61 - 90
Between 90 - 100+
I don't know
Have you ever experienced any of the following? (Check all that apply)
*
Heart problems such as angina, heart failure, irregular heartbeats, or have had a heart attack
Heart or artery malformation
Stroke
Retinitis pigmentosa, a rare genetic eye disease
Severe vision loss, including a condition called NAION
Stomach ulcers
Bleeding problem
Bent/deformed penis shape or Peyronie’s disease
Eection that lasted more than 4 hours
Blood cell problems such as sickle cell anemia, multiple myeloma, or leukemia
Trauma to the pelvic area
None of the above
Other
What do you think causes the issues with your sexual function? (Check all that apply)
*
Aging / getting older
Stress
Surgery
Medications
None of the above
Other
In the last 3 months, have you used ay of the following recreational drugs? (Check all that apply)
*
Cocaine
Poppers
Amphetamines
Opiods/Heroin
No - I have not used any recreational drugs in the past 3 months
Other
Why would you like to start taking Telmisartan (generic for Micardis)? (Check all that apply)
*
Lower blood pressure
Improve blood flow
Increase overall endurance
Improve metabolic health
Support healthy LDL and HDL levels
Lower diabetes risk
Reduce risk of dementia and cognitive impairment
Do you have or have had a history of any of the following conditions?
*
Congestive heart failure
Electrolyte imbalances (e.g., high potassium or low sodium in the blood)
Prone to dehydration
Renal Artery Stenosis
None of these
Are you currently taking or do you have a history of taking any of the following medications? (Check all that apply)
*
Aliskiren
Blood pressure medication
Blood thinners
None of the above
What was your most recent systolic blood pressure reading (the top number)?
*
Please Select
Between 80 - 100
Between 101 - 159
Between 160 - 200+
I don't know
What was your most recent diastolic blood pressure reading (the bottom number)?
*
Please Select
Between 50 - 60
Between 61 - 90
Between 90 - 100+
I don't know
By continuing, you acknowledge and understand that this is a telemedicine visit and does not replace the need to seek routine care with your primary care provider.
*
I acknowledge and understand
Please upload a GOVERNMENT ISSUED PHOTO ID (E.G. DRIVER'S LICENSE).
*
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Please upload a PHOTO OF YOU (E.G. SELFIE PHOTO).
*
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Email
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