Hormone Optimization Intake Form (Male)
Optimize by JaeNix | Jessica Boggs, MSN, APRN, FNP-C, ENP-C
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Health History
Please complete in its entirety.
What are your goals for treatment? Do you have any specific concerns you would like addressed?
*
Please list any medical conditions you have been diagnosed with such as high blood pressure.
*
What surgeries have you had and when?
*
Hospitalizations?
*
Have you ever been on testosterone replacement? Please describe your history of prescribed or illicit steroid use:
*
What medications and/or supplements are you currently taking?
Please list any allergies you have to medications or supplements?
*
What conditions or diseases do you know are in your family history?
*
What symptoms are you currently experiencing?
Fatigue
Brain Fog
Lack of Motivation
Anxiety
Depression
Decreased Mental Clarity
Hot Flashes
Night Sweats
Decreased Libido
Decreased Muscle Mass
Decreased Strength
Weight Gain
Heat/Cold Intolerances
Hair Thinning/Hair Loss
Sleep Disturbances (sleeping more/less than normal)
Acne
Constipation
Diarrhea
Abdominal Pain/Cramping with Food
Bloating
Gas Pains
Nausea/Vomiting
Other
If "Other" Symptoms, Please List:
TX Driver's License # (in order to ship testosterone)
*
UPLOAD PHOTO OF DRIVERS LICENSE - FRONT AND BACK PHOTO
*
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Health Habits
Exercise Frequency
*
Sedentary
Mild Exercise
Moderate Exercise
Regular Vigorous Exercise
Are you dieting? If so, what type of diet?
*
Do you consume alcohol? If yes, please describe your alcohol intake:
*
Do you use tobacco? If yes, how much?
*
Do you use any recreational drugs? If yes, what kind and how often?
*
Are you sexually active?
*
Yes
No
Are you wanting to have children in the future?
*
Yes
No
Have you been diagnosed with HIV?
*
Yes
No
Family Health History
Please describe your family health history. Please include conditions such as prostate cancer, heart attacks, stroke, diabetes, high blood pressure etc. Please also include their age or if they are deceased.
Father
Mother
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Siblings
Children
Mental Health
Do you have any issues with anxiety?
*
Yes
No
Do you feel depressed?
*
Yes
No
Do you have problems with eating or your appetite?
*
Yes
No
Do you experience lack of motivation?
*
Yes
No
Do you have trouble sleeping?
*
Yes
No
Men Only
Do you have to get up to urinate at night?
Yes
No
Do you have discomfort with urination?
Yes
No
Has the force of your urination decreased?
Yes
No
Have you had any kidney, bladder, or prostate infections within the last 12 months?
Yes
No
Do you have any problems emptying your bladder completely?
Yes
No
Do you have problems achieving or maintaining an erection?
Yes
No
Are your erections softer than they used to be?
Yes
No
Do you have ejaculation issues?
Yes
No
Any testicle pain or swelling?
Yes
No
Date of last prostate and rectal exam:
Please explain any yes answers from the previous questions or tell us anything else you would like us to know:
Personal history of prostate cancer?
Yes
No
Please indicate the services you are interested in:
HRT/TRT
Erectile Dysfunction Treatment
Growth Hormone Optimization
Nutritional Supplementation
Anti-Aging Services
Weight Loss
Signature
*
Signature Verification Statement: By signing, I affirm that I have answered all questions truthfully and to the best of my knowledge. I confirm that I am a current resident of the State of Texas and that the identification provided is my valid, Texas-issued driver’s license, used as proof of residency for the purpose of being prescribed testosterone within the state of Texas.
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