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Men’s Hormone EvaluationGregory Peterson2023-05-16T19:05:42-04:00

Men’s Evaluation

Please fill out the form below to the best of your ability.

About You

About You

First Name *

Last Name *

Age *

Birthday *

Address *

City *

State *

Zip Code *

Phone *

By providing my number, I agree to receive SMS messages.

Alternative Phone

Email *

Preferred Method of Contact *

Occupation *

Marital Status *

Do you understand what Bio-Identical Hormone Replacement is? *

Learn More about BHRT

Medical Information

Medical
Information

Primary Care Provider *

Phone *

Address *

Fax

Do you have another primary care provider to add?

Yes

No

Primary Care Provider (2) *

Phone *

Address *

Fax

Do you have another primary care provider to add?

Yes

No

Primary Care Provider (3) *

Phone *

Address *

Fax

Personal Medical Information

Height *

Weight *

Drug Allergies

Allergies to food, pollens, etc.

Tobacco Use *

Alcohol Use *

Please indicate self or family next to each condition that applies

Heart Disease

Date of diagnosis & additional notes

Stroke

Date of diagnosis & additional notes

Clotting Defect

Date of diagnosis & additional notes

Kidney Disease

Date of diagnosis & additional notes

Colitis/IBS

Date of diagnosis & additional notes

Fibromyalgia/Chronic Fatigue

Date of diagnosis & additional notes

Diabetes

Date of diagnosis & additional notes

Epilepsy

Date of diagnosis & additional notes

Arthritis

Date of diagnosis & additional notes

Asthma

Date of diagnosis & additional notes

Osteoporosis

Date of diagnosis & additional notes

High Cholesterol

Date of diagnosis & additional notes

Thyroid Disease

Date of diagnosis & additional notes

Depression

Date of diagnosis & additional notes

Headaches/Migraines

Date of diagnosis & additional notes

Autoimmune Disease

Date of diagnosis & additional notes

Cancer

Date of diagnosis & please specify type(s) of cancer

Do you currently have both testicles? *

If no, please indicate why

Other Conditions (please list)

Have you had any recent lab results you wish to include *

Please upload your lab results here

Prescription Information

Prescription
Information

Please list any PRESCRIPTION medications you are currently using

Please List ALL Over-The-Counter (OTC) products you currently use, both occasionally and regularly.
PLEASE INCLUDE vitamins, minerals, herbal products, pain relievers, cold medicine, sleep aids, etc...

Current Symptoms

Current
Symptoms

Move the slider for EACH SYMPTOM which best describes how you have been feeling.

0 = None (symptom not present)

1 = Mild (present but not distressing)

2 = Moderate (distressing, but not interfering with daily life)

3 = Severe (very distressing, interferes with daily life

Headaches

Anxiety

Breast Enlargement

Burned Out Feeling

Irritable

Decreased Mental Sharpness

Sleep Disturbances

Decreased Stamina

Depression

Decreased Urine Flow

Decreased Erections

Decreased Spontaneous Morning Erections

Increased Urinary Urge

Weight Gain in Waist

Prostate Problems

Decreased Libido

Aches & Pains

Cold Body Temperature

Hot Flashes

Night Sweats

Stress

Foggy Thinking

Loss of Motivation

Inability to Lose Weight

Fatigue

Constipation

Bone Loss

Decreased Muscle Mass

Oily Skin

Please describe more thoroughly any unusual symptoms you may be experiencing

Which 3 symptoms bother you the most? *

Submit

Submit

Were you referred by someone? *

If Yes, by whom?

Without a doctor’s referral I agree to pay the non-refundable $125.00 consultation fee. Please have payment ready when you schedule your appointment. *

For questions regarding what all the consultation fee includes, please contact us at 937-761-2606.

I have read and understand the Hormone Treatment Policy, Electronic Communication Disclaimer & Privacy Policy

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