Hormone Optimization Intake Form (Female)

Kindly submit the intake form prior to your consultation
Optimize by JaeNix | Jessica Boggs, MSN, APRN, FNP-C, ENP-C

First Name *

First Name

Last Name *

Last Name

Email *

[email protected]

Address

Street Address

City

State

Country

Postal Code

Phone Number *

Please enter a valid phone number.

Date of birth *

Date

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? *

Are there any medical conditions that run in your family? *

What symptoms are you currently experiencing? *

Fatigue

Brain Fog

Lack of Motivation

Anxiety

Depression

Decreased Mental Clarity

Decreased Libido

Decreased Muscle Mass

Decreased Strength

Weight Gain

Heat/Cold Intolerances

Hair Thinning/Hair Loss

Sleep Disturbances (sleeping more/less than normal)

Acne

Constipation

Diarrhea

Abdominal Pain/Cramping with Food

Bloating

Gas Pains

Nausea/Vomiting

Erectile Dysfunction

Other

If "Other" Symptoms, Please List:

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

UPLOAD PHOTO OF DRIVERS LICENSE - FRONT AND BACK PHOTO *

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 5 Files )

Upload a copy of your most recent labs here, must be within 90 days.

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Health Habits

Exercise Frequency *

Sedentary

Mild Exercise

Moderate Exercise

Regular Vigorous Exercise

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

Any alcohol intake? *

Yes

If yes, how much?

Do you use tobacco or nicotine products? *

Yes

If yes, what type and amount?

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

Are you sexually active? *

Yes

Are you currently pregnant/breastfeeding? *

Yes

Are you trying to get pregnant in the future? *

Yes

Do you experience painful intercourse *

Yes

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

Do you feel depressed? *

Yes

Do you have problems with eating or your appetite? *

Yes

Do you experience lack of motivation? *

Yes

Do you have trouble sleeping? *

Yes

Date of last pap smear: *

Have you had a prior hysterectomy? Total/Partial? *

Please explain any yes answers from the previous questions or tell us anything else you would like us to know: *

Please select the areas of interest you would like to discuss:

HRT/BHRT/TRT

Peptides/Anti-Aging

Aesthetics

Sexual Wellness

Weight Loss

Non-Surgical Hair Restoration

Direct Primary Care

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.