• PGRxWellness Patient Intake & Medical Evaluation

    Please complete this form to help our clinical team assess your health history, goals, and eligibility for personalized wellness programs.

  • Patient Information

  • Date of Birth*
     - -
  • Sex at Birth*
  • Format: (000) 000-0000.

  • Medical History

  • Medical history conditions*

  • Medications, Allergies, and Social History

  • Allergies*
  • Tobacco use*
  • Alcohol use*
  • Recreational drug use*

  • Pregnancy / Hormonal Status, Health Goals, and Services of Interest

  • Pregnancy / Hormonal Status*
  • Health Goals*
  • Services of Interest*

  • IV Therapy Conditional Section

  • Have you had IV therapy before?*
  • Have you ever fainted with needles or blood draws?*
  • Do you have kidney disease?*

  • Peptides / Weight Management Conditional Section

  • History of Pancreatitis
  • History of Gallbladder Disease
  • History of Thyroid Cancer

  • BHRT / Hormone Therapy Conditional Section

  • Which symptoms are you currently experiencing?
  • Are you currently using hormone therapy?*

  • Functional Medicine / Lab Testing Conditional Section

  • Are you interested in advanced lab testing?*
  • Areas of interest

  • Regenerative Medicine Conditional Section

  • Legal Acknowledgments

  • Acknowledgment of Compounded Medications*
  • Insurance Coverage Acknowledgment*
  • Financial Responsibility Acknowledgment*

  • Telehealth Consent

  • Signature

  • Date*
     - -
  • Should be Empty: