1. Personal Information

Full Name

Date of Birth

Age

Sex Assigned at Birth
MaleFemale

Gender Identity
MaleOther

Phone Number

Email

Address

Emergency Contact Name

Emergency Contact Phone

2. Primary Health Concerns

Low energyFatigueDecreased libidoErectile dysfunctionWeight gainDifficulty losing weightBrain fogMuscle lossPoor sleepMood swings or depressionOther

3. Medical History

Heart diseaseHigh blood pressureStroke or blood clotsDiabetesCancerLiver diseaseKidney diseaseSleep apneaProstate issuesDepression/anxietyThyroid disorderOther

Do you see a primary care provider?
YesNo

If yes, provider name

4. Medications & Supplements

Current medications (name & dosage)

Supplements or vitamins

Allergies

5. Lifestyle & Habits

Tobacco Use
NeverFormerCurrent

Packs per day

Alcohol Use
NeverOccasionallyRegularly

Drinks per week

Recreational Drugs
NoYes

Type/Frequency

Exercise Frequency
None1-2x/week3-5x/weekDaily

Diet Type
StandardLow CarbHigh ProteinVeganOther

Sleep hours per night

Stress Level
LowModerateHigh

6. Sexual & Hormonal Health

LibidoErectionsStaminaConfidenceSensitivity

Have you been treated with:

Testosterone Replacement TherapyClomid or HCGPeptide TherapyED MedicationsThyroid MedicationsOther hormone therapy

Recent lab work?
YesNo

Upload lab results

7. Goals of Treatment

Increased energyImproved libido or sexual performanceFat lossMuscle gainBetter sleepMental clarityAnti-aging or longevityAthletic performanceOther

8. Consent & Authorization

I understand that therapies are elective and I consent to consultation and lab review.

I agree to provide honest and accurate health information.

I understand lab work may be required.

Signature (Type Full Name)

Date

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