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Step 1 of 10 - Personal Information

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Choose The Location Nearest You(Required)
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Name(Required)
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Address(Required)
Email(Required)

Family Physician and/or Primary Health Care Provider:

Do you request your protected health information to be released to you:
Do you request your protected health information be released to anyone other than you?
Do you request your protected health information be disclosed to your Family Physician/Primary Care Provider?:

Occupation:

Marital Status:

FAMILY HISTORY

(All forms)

Weight Loss Questions

Have you ever stayed the same weight for 10 or more years?
Have you attempted to lose weight before?
Previous weight loss methods? (please list)

Medical History: Please check all that apply

Please specify your genetic origin:

Do you now or have you ever had: (check all that apply)
Do you now or have you ever had: (check all that apply)
Other medical conditions (please list):
Hospitalizations or Surgeries (please list):
Are you currently under the care of a physician?
Are you currently under the care of a dermatologist?
Have you recently plucked, tweezed, waxed or used a hair depilatory cream?
Have you had any recent sun exposure, been in a tanning bed or used self-tanning cream?
Do you Smoke?
What do you smoke?
Do you consume alcohol?
Have you received local anesthesia (Lidocaine/Novocain/Xylocaine) by a dentist or doctor?
Did you have an adverse reaction?
My interests or concerns:
Are you using Contraception?
Are you breastfeeding?
During pregnancy did you develop hyperpigmentation or masking?
Do you have regular periods?
Are you going through menopause?
Are you receiving Hormone Replacement Therapy?
Was it Normal?
Was it Normal?
Are you still Menstruating?
Any history of Prostate problems?

CURRENT MEDICATIONS

Drug allergies:
Please List your allergies:
Current Medications
 
What medications have you taken in the last year that you not presently taking now.
 

Symptom Questionnaire

Please select a number for each symptom ranging from 0, meaning no symptoms, to 10, meaning severe symptoms, to let us know how you are feeling today.
012345678910
Sleep Disturbances
Depression
Irritability
Anxiety
Mood Swings
Migraine Headaches
Palpitations
Please select a number for each symptom ranging from 0, meaning no symptoms, to 10, meaning severe symptoms, to let us know how you are feeling today.
012345678910
Painful Intercourse
Night Sweats
Hot Flashes
Dry Skin
Chronic Fatigue
Restless Leg Syndrome
Hair Loss (Women)
Please select a number for each symptom ranging from 0, meaning no symptoms, to 10, meaning severe symptoms, to let us know how you are feeling today.
012345678910
Fatigue
Weight Control
Low Sex Drive
Erectile Dysfunction
Poor Focus
Body Joint Pains
Memory Lapses
Low Exercise Tolerance
Loss of Muscle Tone

MEDICAL RECORDS RELEASE FORM

To request the release of medical information
Name
If you would like the records mailed, provide the address below.
Consent
Name

Submission Consent

Notice of Privacy Practice
Disclosures Statement
Consent
Aesthetics Consent
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