HRT/ Peptide Patient Intake Form

HRT & Peptide Patient Intake

Please complete this form to help us understand your health background and suitability for Hormone Replacement and or Peptide Therapy.
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Height (inches)*
Weight (pounds)*
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Assigned Sex at Birth*

FemaleMale
Please indicate if you have experienced or been diagnosed with any of the following conditions:*

High blood pressureHeart diseaseBlood clotsCancerStrokeLiver diseaseDiabetesThyroid disordersSleep apneaNone of the aboveOther
Are you currently experiencing any of the following symptoms? (Select all that apply)*

Hot flashes or night sweatsMood changes or depressionFatigueDecreased libidoSleep disturbancesVaginal dryness (if applicable)Erectile dysfunction (if applicable)Memory or concentration issuesNone of the aboveOther
Please list any current medications, supplements, or herbal remedies you are taking.*
Do you have any allergies? If yes, please list them.*

Lifestyle Factors*

Please indicate if any of your immediate family members have a history of the following conditions:

Breast cancerOvarian cancerProstate cancerHeart diseaseDiabetesNone of the aboveOther
Is there anything else you would like your provider to know regarding your health or goals for HRT?
File Upload*

Copy of Drivers License as required for controlled substance (Testosterone)
Cancelof
Please sign below to confirm the information provided is accurate to the best of your knowledge.*
Should be Empty:

HRT & Peptide Patient Intake