Welcome! Please fill out the following medical history form so that we can move towards setting your appointment with one of our board-certified providers. Please note that we do require relevant labs prior to starting treatment and every 6 months for hormone optimization patients. We will review your information and make sure you have everything you need prior to meeting with your provider. We look forward to welcoming you to the No Limits Family!

Please be sure to fill out ALL the required fields (marked with a *). You will have difficulty submitting the form if all the required fields are not filled out.

Male/Female *

Phone - Please use THIS FORMAT +1XXXXXXXXXX *

Do you have a separate shipping address? *

If yes, please list your shipping address here - No PO Boxes Please.

Please briefly tell us the reason for your visit. *

Do you have any allergies? *

Yes

If you have allergies, please list

What is your occupation? *

May we thank someone for your referral?

What medications do you take? (Please list with dose and frequency - if none, state NONE) *

Do you take any nitrite medications? (Such as nitroglycerin) *

Yes

I'm not sure

Do you take any blood thinners? (Such as coumadin or Plavix) *

Yes

I'm not sure

What is your height? *

What is your weight? *

Do you experience any of the following: *

How many hours of sleep do you get per night (on average)? *

Do you feel that you eat a healthy, well-balanced diet? *

Yes

Sometimes

Could be better

How many days per week do you workout or get exercise? *

1 to 3

4 or more

Do you have a primary care provider that you have seen within the past 2 years? *

Yes

How much alcohol do you drink per week (on average)? *

1 to 4

5 to 7

More than 7

Do you smoke? *

Yes

Do you vape? *

Yes

Do you chew tobacco? *

Yes

Have you ever been on hormone therapy in the past? *

Yes

Do you have a PERSONAL history of any of the following? *

Do you have a FAMILY history of any of the following? *

Have you had any of the following surgeries? *

Do you plan to have children in the future? *

Yes

I'm not sure

Do you have labwork to upload? (Preferably within the past 6 months)

Driver's License State *

Drivers License Number *

Please upload a valid state ID *

I understand that I am agreeing to receive SMS and/or email messages from No Limits Medical, LLC that may contain information about appointments, updates or marketing. These messages may be sporadic and local carrier rates may apply for you as a user. You can opt out of messaging from No Limits Medical, LLC at anytime by replying STOP to any messages or by contacting us at [email protected] *

I AGREE

I DO NOT AGREE

Please read and agree to the Telehealth Consent HERE

Telehealth Consent *

I AGREE

I DO NOT AGREE

Please read and agree to our Compounded Medications information HERE

Compounded Medications Information *

I AGREE

I DO NOT AGREE

Please select the Initial Provider Visit option below to continue. Thank you and welcome to the No Limits Family!

Please see the following links for our Terms and Conditions, Privacy Policy, and Cancellation and Refund Policy.