Dr. Lori's R3AL3 for Men's Lifegevity

Are you ready to age successfully?

Let's get started.
Dr. Lori's R3AL3 Integrative Medicine Program

Pease fill out form and CLICK SUBMIT at the end. You will receive a notice that your form has been submitted. On the "Thank You" confirmation there is a link to schedule your complimentary consultation. Please allow 24-48 hours for a representative from our office to confirm your complimentary consultation appointment and get all your paperwork started.

**(BHRT) = Bioidentical Hormone Replacement Therapy)
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Name*

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Birthdate*

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Email*
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Address*

Street Address

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Marital Status*

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Referral Source: Please let us know how you found about us!*
Please tell us who referred you. (Name of Referral Source) *
Please state your height, weight & occupation.*
Name of Primary Care Physician, Address & Phone Number *
Pharmacy Name & Phone Number *
Name of Insurance Provider *
Insurance Type (ie. HMO, PPO)*
Allergies: Please check all that apply*

Drug AllergiesDye AllergiesFood AllergiesPet AllergiesSeasonal AllergiesOther
Please list your specific allergy and type of reaction:*
Please list current prescription medications and nutritional supplments (please have them available during your virtual consultation.) Please note: NAME, STRENGTH, DATE STARTED & HOW OFTEN PER DAY*
Over the counter (OTC) issues. Please check all products that you use at least once or more per month.*

Pain RelieverSleep AidsAntidiarrhealLaxitive / Stool SoftenerDiet Aids / Weight Loss ProductsAntacidsOther
Do you use any of the following (check if yes):*

TobaccoVapeAlcoholCaffeine
Hormones previously or currently taking (List NAME, DATE START, DATE STOPPED, REASON)*
Do you have any of the following? Check all that apply.*

ArthritisAsthmaCancerClotting ProblemsDepressionDiabetesEczemaUlcersAnxiety DisorderStrokeHeart DiseaseHigh Cholesterol or LipidsHigh Blood PressureEye Disease / GlaucomaMigraines / HeadachesOsteoporosisThyroid DiseaseUclersEmphysema / COPDFibromyalgiaGERDSeizure DisorderIrritable BowelDepressionAutoimmune DiseaseOther
Do you have any of the following? Check all that apply.*

Sleep IssuesWeight GainWeight LossHair LossDecreased LibidoErectile DysfunctionNight SweatsIrritabilityMood SwingsFluid RetentionFatigueMemory LossBrain FogFrequent Urination / Urinary RetentionDifficulty reaching orgasmIndigestionCold Hands / FeetDiarrhea / ConstipationSensitivity to Heat / ColdDifficulty Waking UpJoint PainsVision Changes / Blurred VisionLoss of SmellMetallic Taste / Loss of TasteChronic Post Nasal DripChronic Nasal CongestionShortness of BreathCoughLack of Exercise ToleranceMuscle Cramping / SpasmsReynaud's Syndrome (white fingertips suddenly)History of Lyme DiseaseHistory of Chronic HPVHistory of Chronic Mold ExposureHistory of Covid with presumed Long HaulerFrequent Electric ShocksTingling in hand or feetLack or AppetiteFrequent Food Cravings
Please expand on any symptoms checked above and list any other symptoms that you are experiencing not list above.*
Please list any questions that you may have. *
If you are interested in Dr. Lori's R3AL3 Weight Management Program, please complete this section of questions:
Do you have any medical history of the following? Check all that apply:

PancreatitusGallbladder issues / GallstonesMedullary Thyroid CancerRetinopathy
Have you ever used other diet medications? If yes, did you have any problems? Please describe your experience below:
How long have you struggled with your weight?
Do you have any known or presumed food allergies?
Please upload a copy of the front and back of your insurance card.

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Upload RECENT or RELEVANT LABS from the last 12 months

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By typing your name and date below, we will accept this as your signature and acknowledge that you have read and reviewed this questionnaire.*

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PLEASE NOTE BY TYPING YOUR NAME AND DATE BELOW, YOU ACKNOWLEDGE THAT DR. LORI IS NOT FINANCIALLY RESPONSIBLE FOR ANY LABS THAT ARE NOT COVERED BY YOUR INSURANCE COMPANY. WE DO OUR BEST TO GIVE YOU THE MOST ECONOMICAL OPTION POSSIBLE AND HAVE NEGOTIATED PRICES FOR SELF PAY OPTIONS WITH SOME LABS IF REQUIRED. IT IS YOUR RESPONSIBILITY TO CALL YOUR INSURANCE REGARDING LABORATORY CHARGES IN AND OUT OF NETWORK OPTIONS & DEDUCTIBLE INFORMATION.*

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Are you ready to age successfully?

If you are interested in Dr. Lori's R3AL3 Weight Management Program, please complete this section of questions: