Cuda Health
Intake Form
Have you been a client of an HRT clinic in the last 12 months? If so, who?
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Please describe concerns you have, goals for treatment, and anything else you would like us to know.
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How did you hear about us?
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Patient Information
First Name
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Last Name
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Date of birth
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Address
Street Address
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Country
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Postal Code
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Terms of Service
Wellness Goals:
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General Fitness
Decrease % Body Fat
Increase Muscle
Endurance
Strength
Cardiovascular
Increase Energy
Sports Conditioning
Injury Rehabilitation
Interested Services:
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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?
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Are you currently on any type of hormone replacement therapy?
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Any prescription medications you are now taking?
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Any known drug allergies and reactions?
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Any self-prescribed medications, dietary supplements, or vitamins you are now taking?
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Past Medical History
Mark all which apply:
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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