The Panday Group Wellness & Performance Assessment Form
This form helps our clinic review your symptoms, health history, and goals for TRT/HGH/hCG or related wellness and performance care. The assessment takes approximately 10–15 minutes. After submission, our coordinator will send the invoice and payment request for the $100 initial assessment, which includes review, bloodwork requisition if appropriate, and your first follow-up phone consultation. Treatment is not guaranteed and depends on healthcare practitioner review. For questions, email medical@pandaygroup.com
Legal Government Name
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Preferred Medication Shipping Address
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Street Address
Street Address Line 2
City
State
Zip Code
Best Contact Phone Number
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Area Code
Phone Number
Email
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Referred By
What's your gender
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Male
Female
Transgender/Non-binary
Marital Status
Single
Married
Divorced
Widowed
Other
Date of Birth (mm/dd/yyyy)
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Month
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Day
Year
Date Picker Icon
What is your weight (lbs) ?
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What is your height ?
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Please upload 2 forms of government issued identification
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2 (TWO) Forms of government identification include a driver's license, health card, passport, etc. We do not bill any provincial insurance Full ID documents are required for dispensing of controlled substance medications.
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Please upload any bloodwork/medical documentation to support your request
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Full bloodwork with name, date of collection and name of labratory must be shown. NO SCREENSHOTS will be accepted. **Patients that require bloodwork will be provided with a requisition before the appointment with our licensed health practitioner**
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Do you have medical bloodwork documents ?
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Yes
No
How can we help you today ?
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Testosterone Replacement Therapy (TRT)
Human Growth Hormone (HGH)
Human Chorionic Gonadotropin (hCG)
ED Medication
All of the above
Have you spoke to your family physician about the above noted request ?
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Please Select
YES
NO
What brings you in (Select all that applies)
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Decreased libido
Decreased morning erections
Ejaculate too quickly/premature ejaculation
Muscle Loss
Weight Gain
Depression
Sleep Problems
Unusual Sweating
Brain fog
Not able to perform sexually
Get back into a healthier lifestyle
Briefly tell us a little bit about your health goals
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How long have the above symptoms been occurring? (Select one)
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Less than 1 year
Approximately 1 year
2-3 years
4-5 years
> 5 years
Do any of the below improve your symptoms? (Select any that apply)
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Caffeine
Exercise
Sleep
Testosterone
None
Please tell us about any ED medications you have used or are currently using, the doses and how effective they were.
Tell us more about the other symptoms you have been experiencing.
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Do you smoke tobacco, vape nicotine, and/or use other tobacco products?
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Yes
No
What type of tobacco product do you use, how much and how often?
Have you had blood work done to check for diabetes in the last 2 years?
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Yes
No
What was your most recent blood pressure reading?
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Low - Normal120/80 or lower
Above Normalbetween 121/80 to 129/80
High between 130/81 to 139/89
Higher greater than 140/90
I don't know my blood pressure
Confirm
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Confirm
Was your blood work normal?
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Yes
No
I do not know
Describe your experience when you walk up two flights of stairs or 20 blocks on flat terrain:
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These activities don't cause me any problems
Sometimes these activities cause me shortness of breath
Sometimes these activities cause me chest pain
Do you use any recreational drugs? Some drugs may cause life-threatening interactions with ED medications.
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Amyl Nitrate or Butyl Nitrate
Cocaine or Crack
Poppers or Rush
Cannabis
Other
None
Are big life changes or stressors happening to you right now?
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None
Lots of new stress
Some Minor Stress
Not sure
Agreement
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I agree to the privacy policy.
Do any of the following currently apply to you?
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Cancer
Kidney Problems
Liver Problems
Lung or pulmonary problems
Nerve or neurological problems
Using steroids or hormones
None of these apply to me
Have you ever had any of the following medical conditions?
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Abnormal heartbeat, arrhythmia, or congenital QT prolongation
Chest pain or shortness of breath
Condition where you've been told sex is not advised
Diabetes
Eye or vision problems
Heart attack, chest pain, or angina
Heart valve problems or cardiomyopathy
Low blood pressure
Pain when you have an erection
Paralysis
Passing out or fainting
Peyronie's disease
Physical problems, scarring, or other issues related to your penis
Previous prostate or pelvis surgery
Prostate problems
Radiation therapy of the pelvis
Sickle cell anemia
Spinal problems
Stroke or Transient Ischemic Attack (TIA)
Testosterone deficiency
Using nitroglycerin, isosorbide, or any other nitrate medicine
None of these apply to me
Do you have any allergies ?
Do you take any medication, vitamins, herbals, or supplements?
Have you had any surgeries or hospitalizations?
Do you have any medical conditions?
PHQ-9- Patient Health Questionnaire
Over the last 2 weeks, on how many days have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
2. Feeling down, depressed or hopeless
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
3. Trouble falling or staying asleep, orsleeping too much
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
4. Feeling tired or having little energy
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
5. Poor appetite or over eating
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
6. Feeling bad about yourself-or that youare a failure or have let yourself or your family down
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
7. Trouble concentrating on things, such asreading the newspaper or watching television
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
8. Moving or speaking so slowly that otherpeople could have noticed, or the opposite-being so fidgety or restless that you have been moving around a lot more than usual
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
9.Thoughts that you would be better offdead, or of hurting yourself
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
If you checked off any problems, how difficulty have these made it for you to do your work, take care of things at home, or get along with other people?
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Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
GAD-7 Generalized Anxiety Disorder
Over the last 2 weeks, on how many days have you been bothered by any of the following problems?
1. Feeling nervous, anxious, or on edge
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
2. Not being able to stop or control worrying
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
3. Worrying too much about different things
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
4. Trouble relaxing
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
5. Being so restless that it's hard to sit still
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
6. Becoming easily annoyed or irritable
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
7. Feeling afraid as if something awful might happen
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0 - Not at all
1 - Several Days
2 - More than half the days
3 - Nearly every day
If you checked off any problems, how difficulty have these made it for you to do your work, take care of things at home, or get along with other people?
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Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
AMS Questionnaire
Which of the following symptoms apply to you at this time? Please mark the appropriate box for each symptom. For symptoms that do not apply, please mark "none"
Decline in your feeling of general well-being
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Joint pain and muscular ache
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Excessive sweating
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Sleep Problems
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Increased need for sleep, often feeling tired
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Irritability
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Nervousness
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Anxiety
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Physical exhaustion / lacking vitality
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Decrease in muscular strength
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Depressive mood
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Feeling that you have passed your peak
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Feeling burnt out, having bit rock-bottom
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Decrease in beard growth
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Decrease in ability/frequency to perform sexually
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Decrease in the number of morning erections
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Decrease in sexual desire/libido
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1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Adult Growth Hormone Deficiency Assessment
Listed below are some statements which people make about themselves. Read the list carefully and put a tick in the box marked YES if the statement applies to you. Tick the box marked NO if it does not apply to you. Please remember to answer every item. If you are not sure whether to answer YES or NO tick whichever answer you think is most true in general
I have to struggle to finish jobs
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Yes
No
I often feel lonely even when I am with other people.
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Yes
No
I feel a strong need to sleep during the day
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Yes
No
I have to read things several times before they sink in.
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Yes
No
It is difficult for me to make friends.
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Yes
No
It takes a lot of effort for me to do simple tasks.
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Yes
No
I have difficulty controlling my emotions.
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Yes
No
I often lose track of what I want to say.
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Yes
No
I lack confidence
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Yes
No
I have to push myself to do things.
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Yes
No
I feel as if I let people down.
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Yes
No
I often feel very tense.
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Yes
No
I find it hard to mix with people.
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Yes
No
I feel worn out even when I’ve not done anything.
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Yes
No
There are times when I feel very low.
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Yes
No
I avoid responsibility if possible.
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Yes
No
I avoid mixing with people I don’t know well.
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Yes
No
I feel as if I am a burden to other people.
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Yes
No
I often forget what people have said to me.
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Yes
No
I find it difficult to plan ahead.
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Yes
No
I am easily irritated by other people.
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Yes
No
I often feel too tired to do the things I ought to do.
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Yes
No
I have to force myself to do all the things that need doing.
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Yes
No
I often have to force myself to stay awake.
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Yes
No
My memory lets me down.
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Yes
No
Have you got any other major symptoms?
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Yes
No
If Yes, please describe:
The Panday Group fulfills all prescriptions exclusively through our partnered pharmacy network as part of our bundled model of care. Prescriptions are not sent to outside or patient-preferred pharmacies.
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I understand and agree that all medications prescribed through The Panday Group will be dispensed through its approved pharmacy network, and that this is a standard condition of care.
Do you have any questions you would like to ask the healthcare practitioner about testosterone/growth hormone medication ?
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First Assessment - Bloodwork Requisition + Follow-Up Appointment
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First Time Appointment Assessment
Choose your preferred medication
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PLEASE CHOOSE AN OPTION BELOW
STILL NOT SURE NEED ADVICE
Testosterone Replacement Therapy
Taro Testosterone Cypionate Injection 100mg/ml - 10 ML - $ 195.00 CAD
Pfizer Depo Testosterone Cypionate Injection 100mg/ml - 10 ML - $ 220.00 CAD
Compouind Testosterone Cypionate Injection 100mg/ml - 10 ML - $ 250.00 CAD
HCG - Chorionic Gonadotropin (Human)-10 ml - $ 365
Human Growth Hormone Injectables - Genotropin (Somatropin) - Starting at $ 395
ED Medication - Starting at $ 175
Total
$ 100.00 CAD
By initializing and / or signing this document, you affirm that all of the information in this Medical Wellness Agreement is true and you agree to all of the ASSESSMENT, MEDICAL HISTORY, AGREEMENTS, ACKNOWLEDGEMENTS, and terms hereof.
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Please verify that you are human
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