Hormone Optimization Intake Form (Male)

Kindly submit the intake form prior to your consultation

Optimize by JaeNix | Jessica Boggs, MSN, APRN, FNP-C, ENP-C

Email *

Address

Street Address

City

State

Country

Postal Code

Date of birth

Health History

Please complete in its entirety.

What are your goals for treatment? Do you have any specific concerns you would like addressed? *

Please list any medical conditions you have been diagnosed with such as high blood pressure. *

What surgeries have you had and when? *

Hospitalizations? *

Have you ever been on testosterone replacement? Please describe your history of prescribed or illicit steroid use: *

What medications and/or supplements are you currently taking? *

Please list any allergies you have to medications or supplements? *

What conditions or diseases do you know are in your family history? *

If "Other" Symptoms, Please List: *

TX Driver's License # (in order to ship testosterone) *

UPLOAD PHOTO OF DRIVERS LICENSE - FRONT AND BACK PHOTO *

UPLOAD COPY OF LABS (WITHIN 90 DAYS)

Health Habits

Exercise Frequency *

Sedentary

Mild Exercise

Moderate Exercise

Regular Vigorous Exercise

Are you dieting? If so, what type of diet? *

Do you consume alcohol? If yes, please describe your alcohol intake: *

Do you use tobacco? If yes, how much? *

Do you use any recreational drugs? If yes, what kind and how often? *

Are you sexually active? *

Yes

No

Are you wanting to have children in the future? *

Yes

No

Have you been diagnosed with HIV? *

Yes

No

Family Health History

Please describe your family health history. Please include conditions such as prostate cancer, heart attacks, stroke, diabetes, high blood pressure etc. Please also include their age or if they are deceased.

Father

Mother

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Siblings

Children

Mental Health

Do you have any issues with anxiety? *

Yes

No

Do you feel depressed? *

Yes

No

Do you have problems with eating or your appetite? *

Yes

No

Do you experience lack of motivation? *

Yes

No

Do you have trouble sleeping? *

Yes

No

Men Only

Do you have to get up to urinate at night? *

Yes

No

Do you have discomfort with urination? *

Yes

No

Has the force of your urination decreased? *

Yes

No

Have you had any kidney, bladder, or prostate infections within the last 12 months? *

Yes

No

Do you have any problems emptying your bladder completely? *

Yes

No

Do you have problems achieving or maintaining an erection? *

Yes

No

Are your erections softer than they used to be? *

Yes

No

Do you have ejaculation issues? *

Yes

No

Any testicle pain or swelling? *

Yes

No

Date of last prostate and rectal exam: *

Personal history of prostate cancer? *

Yes

No

Signature : *

Clear

Signature Verification Statement: By signing, I affirm that I have answered all questions truthfully and to the best of my knowledge. I confirm that I am a current resident of the State of Texas and that the identification provided is my valid, Texas-issued driver’s license, used as proof of residency for the purpose of being prescribed testosterone within the state of Texas.