First Name
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Last Name
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Phone
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Email
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Date Of Birth
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Preferred Name
Sex Assigned at Birth
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Male
Female
Street Address
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City / State / ZIP
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Best Way to Reach You
Call
Text
Email
Marital Status
Occupation
How Did You Hear About Us?
Referred By (if anyone)
Emergency Contact Name
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Emergency Contact Phone
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Emergency Contact Relationship
What brings you in today?
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What are your goals? (check all that apply)
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More energy
Lose body fat
Build or keep muscle
Improve sex drive
Improve sexual performance
Better sleep
Mental clarity and focus
Better mood
Hormone balance
Recovery or injury healing
Healthy aging
Athletic performance
Other
If we could fix one thing in the next 90 days, what would it be?
When did you last feel your best, and what was different then?
Services you are interested in
Hormone therapy
Peptide therapy
GLP-1 / metabolic program
Functional medicine
Lab testing
Not sure yet
Energy (1 = exhausted, 10 = excellent)
Sex Drive (1 = none, 10 = strong)
Sexual Performance / Satisfaction (1 = very poor, 10 = excellent)
Mental Clarity and Focus (1 = foggy, 10 = sharp)
Memory (1 = poor, 10 = excellent)
Mood (1 = very low, 10 = great)
Motivation and Drive (1 = none, 10 = high)
Sleep Quality (1 = very poor, 10 = excellent)
Stress Level (1 = very low, 10 = very high)
Recovery After Exercise (1 = very slow, 10 = fast)
Satisfaction With Your Body Composition (1 = very unhappy, 10 = very happy)
Hours of Sleep per Night
Do you wake up rested?
Yes
Sometimes
No
Symptoms you have noticed (check all that apply)
Afternoon energy crash
Brain fog
Trouble falling asleep
Waking during the night
Anxiety
Irritability
Low mood
Weight gain around the midsection
Hard time losing weight
Loss of muscle or strength
Joint pain or stiffness
Hot flashes or night sweats
Irregular or heavy cycles
Erectile difficulties
Vaginal dryness
Hair thinning
Cold hands or feet
Sugar or carb cravings
Bloating or digestive issues
Low exercise tolerance
Current Medical Conditions
Past Surgeries or Hospital Stays (with years)
Current Prescription Medications and Doses
Current Supplements
Medication Allergies
Have you used hormone therapy (testosterone, estrogen, progesterone, thyroid)?
Never
In the past
Currently
Have you used a GLP-1 (semaglutide, tirzepatide, etc.)?
Never
In the past
Currently
If yes to either, list what, the dose, and how long
Women only: Menstrual Status
Family History (check all that apply)
Heart disease
Diabetes
High blood pressure
Thyroid disease
Cancer
Stroke
Dementia or Alzheimer's
Autoimmune disease
None known
Have you had blood work in the last 12 months?
Yes
No
Not sure
Height
Current Weight (lbs)
Goal Weight (lbs)
How often do you exercise?
Type of Exercise
Strength training
Cardio
Sports
Walking
Yoga or mobility
None
Describe a typical day of eating (what you eat and drink from waking to bedtime)
Alcohol
Tobacco or Nicotine
Caffeine per Day
Anything else you want us to know?
Acknowledgment
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I confirm the information I provided is accurate and complete to the best of my knowledge.
Type Your Full Name as Signature
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