10 dollar lab TRT Health 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

Priority Clinical Intake Review.

3

What is your name?* This field is required.

First Name

Last Name

4

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

example@example.com

5

What is Your DOB?ex: 01/05/1989

6

Please enter your phone number* This field is required.I will also reach out by texts to reach your needs sooner! - Dr. Rucker

Please enter a valid phone number.

7

What are your top 1–2 primary goals right now?* This field is required.

Fat loss

Energy optimization

Muscle & strength

Libido & performance

Mental clarity

Longevity / anti-aging

9

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

10

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

11

How many days per week do you currently resistance train?

0-1 days

2-3 days

4-5 days

6+ days

12

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

Yes

No

13

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

Trouble falling asleep

Trouble staying asleep

Both

14

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

Yes

No

15

Have you had lab work in the last 6 months?* This field is required.

Yes

No

I would like new labs

16

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

17

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

18

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

Yes

No

Not Sure

19

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

20

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

21

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

22

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.

23

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

Yes

No

Not Sure

24

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

Yes

No

25

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

Yes

No

26

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

Yes

No

Not Sure

27

Briefly describe your biggest current health frustration in your own words.

28

If clinically approved and it feels like the right fit, how soon would you want to begin?

Immediately

Within 30 days

Just exploring options

29

Were you referred to Reverse by someone?We’d love to know so we can thank them properly.

30

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.

31

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

32

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

33

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

I want it delivered

I want THE WORKS! Peptides, Hair Compounds, ED, Etc

34

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

Peptides

ADHD

Erectile Dysfunction Treatment

Hair Loss Treatment

Other

MEDICAL MARIJUANA (Florida Residents Only)

35

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

36

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

Low Testosterone

I Don't Remember

Normal Levels

I Would Like New Labs

37

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

First Responder

Vet

Neither

38

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

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