Full Name
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Phone
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Email
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Address
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City
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State
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Postal code
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Gender
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Select One
Testosterone MEN ONLY
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Lack of Libido (Sex Drive)
Lack of Energy
Decreased Strength of Endurance
Loss of Height
Decreased enjoyment of life or self esteem
Sad or grumpy more often
Erections that are not as strong
Deterioration in ability to play sports or be active
Falling asleep after eating
Deterioration in work performance
Facial Skin more Slack and Wrinkly
Loss of muscle tone
Increased belly fat
Other
Estrogen - WOMEN ONLY
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Achy Joints/Pain
Anxiety/Apathy & Malaise
Bloating
Bone Loss (Osteoporosis)
Difficulty Concentrating
Foggy thinking, unable to focus
Food cravings
Frequent bladder infections
Headaches
Heart Palpitations
Hot Flashes
Incontinence or Urinary Stress
Insomnia
Lethargy or Depression
Low Libido (Sex Drive)
Low self esteem or sense of well being
Memory Lapses
Migraines
Mood Swings
Night Sweats
PMS Symptoms
Reduction in Breast Fullness
Sleep Disturbances
Swelling, Puffiness, Water Retention
Tearfulness
Vaginal Dryness & Irritation
Weight Gain
Progesterone - WOMEN ONLY
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Anxiety & Moodiness
Breast Enlargement
Cyclical Headache
Migraines
Heavy Menses
Irregular Periods
Irritability & Quick to Anger
Not Ovulating
Painful Menstrual Cramps
Puffiness and Bloating
Short Term Memory Loss
Sleep Disturbances
Insomnia
Sugar Cravings
Hypoglycemia
Tender Breasts
Water Retention
Weepiness
Tearfulness
Testosterone - WOMEN ONLY
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Acne
Aggression
Anxiety or Nervousness
Decreased Flexibility
Decreased Mental Ability
Decreased Stamina
Elevated Triglycerides
Excess body hair, face and arms
Fatique
Feeling "Burned Out"
Fibromyalgia
Foggy Thinking
Heart Palpitations
Hypoglycemia, Unstable Blood Sugar
Irritability
Thyroid
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Coarse, dry skin and hair
Cold intolerance
Constipation
Deafness
Diminished Sweating
Physical tiredness
Hoarseness
Pins and needles feelings
Eye puffiness
Slow thought process
Slow movement
Weight gain
Goiter
Nervousness and irritability
Heat intolerance
Increased frequency of stools
Muscle weakness
Increased sweating
Fatigue
Blurred or double vision
Erratic behavior
Restfulness
Heart palpitations
Restless sleep
Decrease in menstrual cycle
Increased appetite
Distracted attention span
Tremors
Tachycardia
Weight loss
Any personal history of cancer or blood clotting?
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Description of personal history of cancer or blood clotting
Any family history of cancer or blood clotting?
Select One
Description of family history of cancer or blood clotting
Have you had a physical in the last 12 months?
Select One
What health conditions have you been diagnosed with?
What is your current list of medications, vitamins, and supplements that you take orally, as an injection, or in any other form?
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Picture(s) of medications
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Have you ever been on hormone treatment and if so, what have you tried so far?
Which one fits you best: never smoker, current smoker, or former smoker (vaping included)? If you are a current smoker, how much do you smoke?
If current smoker, are you willing to quit?
Select one
If former smoker, when did you quit? If never smoker, leave blank.