FR Vet TRT Profile

1

Hey! Let's start simple, which of the following best describes your current state?* This field is required.

Feeling Older

Feeling Stressed

Feeling Lethargic

Feeling Unsure

2

Meet Dr. Rucker

3

Do any of the following statements apply to you?Check all that apply:

I am just looking to boost my testosterone levels

I have less Muscle Mass & More Belly Fat than i would like

I am not doing as well as I would like at work (Lower Mental Clarity)

I have low energy and or motivation in my life

I have trouble pleasing my partner in the bedroom

4

What are your top 1-2 primary goals right now? (Select up to 2)* This field is required.

Fat loss

Energy optimization

Muscle & strength

Libido & performance

Mental clarity

Longevity / anti-aging

6

Have you previously tried GLP-1 medications (like Semaglutide or Tirzepatide) or other weight loss treatments? If yes, how did you respond?

7

What do you struggle with most when it comes to weight? (Select all that apply)

Appetite control

Sugar or carb cravings

Slow metabolism

Emotional eating

Lack of energy to exercise

8

How many days per week do you currently resistance train?

0-1 days

2-3 days

4-5 days

6+ days

9

Do you have any current joint pain, tendon issues, or injuries that limit your training?

Yes

No

10

Do you have trouble falling asleep, staying asleep, or both?

Trouble falling asleep

Trouble staying asleep

Both

11

Are you currently taking any medications for erectile dysfunction (e.g., Viagra, Cialis)?

Yes

No

12

What past investments have you made in your health?Check all that apply:

Gym Membership/Workout Plans

1:1 Personal Trainer / Online Coaching / Nutritionist

At Home Diet Plans

TRT / HGH / Peptides / Functional Medicine/ etc

Peloton / Tonal / Fitness Technology

I have never invested in my health

13

What is your name?* This field is required.

First Name

Last Name

14

Great! What is a good email to have on file?* This field is required.

example@example.com

15

Welcome!Here is a quick video:

16

Are you still interested in learning more about TRT Therapy and Dr. Rucker's approach?

Yes! Let's Talk!

No I'm no longer interested.

I'm not sure, need more info.

I would like to keep filling out the form.

17

Become One Of Dr. Rucker's Success Stories

18

What is your Health Goal over the next year?Please be specific and explain why you need Dr. Rucker’s help. Goals do not need to be physical goals.

19

What do you feel was your Biggest Obstacle to achieving your goal AND/OR sustaining it? Please provide as much detail as you can* This field is required.Biggest obstacle in your way. Don't think too hard, just write what comes to mind

20

Patient Testimonial

21

When is your Birthday?* This field is required.We need your date of birth due to reverse being a medical prescription.

22

Our TRT Delivery Program

23

We try to make working with Dr. Rucker Affordable for all Budgets. If you like what you hear from him during your call how quickly are you ready to start?

Yesterday

Today

Not Ready Yet

Would like More Info First

24

Where are you Located?* This field is required.Example: Sarasota, Florida

25

Which Type of Plan Interests You?This helps Dr. Rucker propose the most realistic option for your Health & Wallet!

I want Monthly TRT Shipped to me for $150 every 8 weeks

I want Monthly TRT Shipped to me ($90/mo)

I want Monthly TRT Shipped as Well as Peptide Therapy (Anavar, Nandrolone, Hair Restoration etc)

26

What Other Treatments Would You Like to Ask Dr. Rucker About?Dr. Rucker can provide custom bundles that are tailored to you if needed.

Hair Loss Treatment

Peptides

ADHD

Erectile Dysfunction Treatment

Medical Marijuana (FL Residents only)

27

Have you ever had labs taken for Low Testosterone? If you are coming from another TRT Clinic we will provide a Discount* This field is required.

Yes

No

I Don't Remember

28

Are You A Veteran or First Responder* This field is required.

Yes

No

29

If Yes, What was the Result?* This field is required.

Low Testosterone

I Don't Remember

Normal Levels

I Would Like New Labs

30

If you have had recent labs, which of the following were included? (Select all that apply)

Total Testosterone

Free Testosterone

Estradiol (E2)

LH / FSH

Complete Blood Count (CBC)

Comprehensive Metabolic Panel (CMP)

PSA (Prostate-Specific Antigen)

Thyroid Panel (TSH)

None of the above

31

Do you have a personal history of prostate cancer or breast cancer?

Yes

No

Not Sure

32

Have you ever been diagnosed with severe sleep apnea, congestive heart failure, or a high red blood cell count (polycythemia)?

Yes

No

Not Sure

33

Are you currently trying to conceive or planning to have children in the near future?

Yes

No

34

Do you currently have an active cancer diagnosis or are you undergoing any form of cancer treatment?

Yes

No

35

Are you currently taking blood thinners, corticosteroids, or insulin?

Yes

No

Not Sure

36

Have you been diagnosed with or treated for PTSD, TBI (traumatic brain injury), or any other service-related mental health condition?

Yes

No

Prefer not to say

37

Please provide additional details about your cancer history so our medical team can review before recommending any TRT protocol.

38

Please describe your condition and when you were diagnosed so our medical team can assess appropriately.

39

Important: Standard TRT can suppress natural testosterone production and reduce sperm count. Our team will discuss fertility-preserving options such as HCG or Enclomiphene with you during your consultation.

40

Thank you for sharing that. Dr. Rucker takes a holistic approach with Veterans and will take your full history into account when building your protocol.

41

You can upload your labs here for Dr Rucker if you have them on handYou can also send you labs at any time to Labs@reversepractices.com

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

42

If you would like New Labs, we can send you a lab script to your email.

I want new Labs!

Want to speak to Dr. first

Not at this time

43

ONE LAST STEP! Enter your phone number & Click NEXT to have a Success Coach reach out to you for a call with Me. On this call, we will see if you are a good fit and give you a full breakdown of our program. * This field is required.I will also reach out by texts to reach your needs sooner! - Dr. Rucker

Please enter a valid phone number.

44

REAL PATIENT 6 MONTH LAB REVIEW -Dr Rucker