• Funk Roberts | The Panday Group Wellness & Performance - Patient Assessment Form

    Welcome, Funk Roberts Clients. This confidential patient assessment is provided by The Panday Group Wellness & Performance and is available to residents of Canada.
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  • Which clinical assessment applies to you?*
  • What's your gender*
  • Marital Status
  • Date of Birth (mm/dd/yyyy)*
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  • Which Wellness & Performance assessment would you like to continue with?*

  • Women’s Hormonal Health Assessment

  • Current menstrual status*
  • Do you currently have a uterus?*
  • Current ovarian status*
  • Have you had a hysterectomy, ovary removal, endometrial ablation, or other gynecologic surgery?*
  • Are you currently pregnant, breastfeeding, trying to conceive, or planning pregnancy within 12 months?*
  • Menopause symptom severity*
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  • How much do your symptoms interfere with sleep, work, exercise, relationships, or daily life?*
  • Which genitourinary or sexual-health symptoms are you experiencing?*
  • Which women’s hormone treatments have you previously or currently used?*
  • First day of your last menstrual period
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    2 digit month, 2 digit day, 4 digit year
  • Have you had any bleeding or spotting after 12 consecutive months without a menstrual period?*
  • Do any of these hormone-therapy safety considerations apply to you?*
  • Relevant family medical history*
  • Do you currently have a breast lump, nipple discharge, or a new breast change?*
  • Do you have medical bloodwork documents ?*
  • How can we help you today ?*
  • What brings you in (Select all that applies)*
  • How long have the above symptoms been occurring? (Select one)*
  • Do any of the below improve your symptoms? (Select any that apply)*
  • Do you smoke tobacco, vape nicotine, and/or use other tobacco products?*
  • Have you had blood work done to check for diabetes in the last 2 years?*
  • What was your most recent blood pressure reading?*
  • Was your blood work normal?*
  • Describe your experience when you walk up two flights of stairs or 20 blocks on flat terrain:*
  • Do you use any recreational drugs? Some drugs may cause life-threatening interactions with ED medications.*
  • Are big life changes or stressors happening to you right now?*
  • Do any of the following currently apply to you?*
  • Have you ever had any of the following 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?
  • PHQ-9 symptom frequency*
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  • 1. Little interest or pleasure in doing things*
  • 2. Feeling down, depressed or hopeless*
  • 3. Trouble falling or staying asleep, orsleeping too much*
  • 4. Feeling tired or having little energy*
  • 5. Poor appetite or over eating*
  • 6. Feeling bad about yourself-or that youare a failure or have let yourself or your family down*
  • 7. Trouble concentrating on things, such asreading the newspaper or watching television*
  • 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*
  • 9.Thoughts that you would be better offdead, or of hurting yourself*
  • 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?*

  • GAD-7 Generalized Anxiety Disorder

    Over the last 2 weeks, on how many days have you been bothered by any of the following problems?
  • GAD-7 symptom frequency*
    Rows
  • 4. Trouble relaxing*
  • 5. Being so restless that it's hard to sit still*
  • 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?*

  • 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"
  • AMS symptom severity*
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  • 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*
  • I often feel lonely even when I am with other people.*
  • I feel a strong need to sleep during the day*
  • I have to read things several times before they sink in.*
  • It is difficult for me to make friends.*
  • It takes a lot of effort for me to do simple tasks.*
  • I have difficulty controlling my emotions.*
  • I often lose track of what I want to say.*
  • I lack confidence*
  • I have to push myself to do things.*
  • I feel as if I let people down.*
  • I often feel very tense.*
  • I find it hard to mix with people.*
  • I feel worn out even when I’ve not done anything.*
  • There are times when I feel very low.*
  • I avoid responsibility if possible.*
  • I avoid mixing with people I don’t know well.*
  • I feel as if I am a burden to other people.*
  • I often forget what people have said to me.*
  • I find it difficult to plan ahead.*
  • I am easily irritated by other people.*
  • I often feel too tired to do the things I ought to do.*
  • I have to force myself to do all the things that need doing.*
  • I often have to force myself to stay awake.*
  • My memory lets me down.*
  • Have you got any other major symptoms?*
  • Initial Wellness & Performance Assessment — $100 CAD
    Includes patient-file creation, review of your completed assessment and available bloodwork, and preparation of a bloodwork requisition when required. Treatment eligibility and medication options will be discussed after clinical review.

  • Total

    $ 100.00 CAD

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