Cuda Health

Intake Form

Have you been a client of an HRT clinic in the last 12 months? If so, who? *

Please describe concerns you have, goals for treatment, and anything else you would like us to know. *

How did you hear about us? *

Patient Information

First Name *

Last Name *

Date of birth *

Address

Street Address *

City *

State *

Country *

Country

Postal Code *

Email *

Phone *

Biological Sex *

Privacy Policy | Terms of Service

Wellness Goals: *

General Fitness

Decrease % Body Fat

Increase Muscle

Endurance

Strength

Cardiovascular

Increase Energy

Sports Conditioning

Injury Rehabilitation

Interested Services: *

Hormone Therapy

Peptide Therapy

Weight Loss

Athletic Performance & Recovery

Sexual Health

Sleep Treatment

Skin Rejuvenation

Hair Growth

Thyroid Function

Fertility

Vitamin Therapy

Any other medical or diagnostic tests you have had in the last two years? *

Are you currently on any type of hormone replacement therapy? *

Any prescription medications you are now taking? *

Any known drug allergies and reactions? *

Any self-prescribed medications, dietary supplements, or vitamins you are now taking? *

Past Medical History

Mark all which apply: *

None

Heart Attack

Stroke

Diseases of the arteries

Varicose Veins

Asthma

Heart Murmur

High Cholesterol

Cancer

Diabetes or abnormal blood sugar levels

Rheumatic Fever

Ulcers

Arthritis of legs or arm

Liver Disease

Gout

Migraines

Kidney Disease

Hepatitis

Epilepsy or Seizures

Depression

Anxiety

Anemia

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