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Your Final Step Before A Free Confidential Medical Consultation
PLEASE READ: Congratulations on your personal interest in our co-created Physicians Prescribed Hormone Replacement Therapy (HRT) programs, before we can effectively consult you and give you the best level of medical service, it is required that you fill out our confidential medical history form. Please take 5 minutes of your time right now and complete this medical history form. We will call you within 24 hours. Please make sure you provide a valid phone number and email, or we will be unable to contact you. You must be a US Citizen and atleast 30 years old in older to qualify.
After successfully completing and submitting the confidential medical form, please call our medical center @ 1-800-650-1518.
The following form establishes guidelines and conditions required for the use of hormone replacement therapy (HRT) involving DEA "controlled" or” scheduled" medications. Patient(s) agree that these guidelines and conditions are an essential factor in maintaining a successful patient/physician relationship.
PERSONAL INFORMATION FORM
Your Name:
Last Name: First Name:
Email Address:
Confirm Email:
Phone Numbers (must be valid):
Day Phone: Evening Phone:
Confirm Day Phone: Confirm Evening Phone:
Best Time to Reach / Contact You:
Patient Address:
Street
City United States:
Zip Code: Country (USA Only):
CONFIDENTIAL MEDICAL HISTORY INFORMATION
Date of Birth: / / I am at least 30 years old:
Weight:
Gender:    Male    Female Height:
Patient History: Do you have or have your ever had any of the following? If the answer to any is yes, please check and explain below
Any known deficiency including minerals and electrolytes:
Yes
No
Blood disorders:
Yes
No
Cancer:
Yes
No
Carpal Tunnel syndrome:
Yes
No
Chemical Dependency:
Yes
No
Drug allergies:
Yes
No
Edema/excess fluid retention:
Yes
No
Emotional disorders:
Yes
No
Genital-Urinary disorder:
Yes
No
Glaucoma:
Yes
No
Heart Attack:
Yes
No
Heart disease including Atherosclerosis, Angina, Heart Failure:
Yes
No
Hyperlipidemia:
Yes
No
Hypertension:
Yes
No
Immune disorders:
Yes
No
Lactating:
Yes
No
Lung disorder:
Yes
No
Neurologic disorders, Thyroid, Diabetes or other endocrine disorder including insulin resistance, or diabetes:
Yes
No
Orthopedic or muscle disorder including fracture or joint disorders:
Yes
No
Poor wound healing:
Yes
No
Regularly exercise
 (if yes, describe type, frequency and duration)
Yes
No
Renal disease:
Yes
No
Surgery:
Yes
No
Upper respiratory:
Yes
No
Use of medications:
(if yes, list medications below)
Yes
No
Other illnesses:
Yes
No
Family History: Does a relative have or have ever had any of the following? If the answer to any is yes, please check and explain below
Cardiovascular disease:
Yes
No
Diabetes, thyroid or other:
Yes
No
Endocrine Disorder:
Yes
No
Hypertension:
Yes
No
Lipid Disorder:
Yes
No
Other forms of cancer:
Yes
No
Prostate cancer:
Yes
No
Other illnesses:
Yes
No
Questions for Treatment: Do you have or have your ever had any of the following? If the answer to any is yes, please check and explain below
Cold or heat intolerance:
Yes
No
Decreased desire and ability to exercise:
Yes
No
Decreased energy or endurance:
Yes
No
Decreased sense of well-being:
Yes
No
Decreasing memory:
Yes
No
Decreasing muscle strength:
Yes
No
Decreasing size of testicals:
Yes
No
Depression:
Yes
No
Difficulty sleeping:
Yes
No
Hot flashes:
Yes
No
Increased lack of drive:
Yes
No
Increasing fat deposits about abdomen or thighs:
Yes
No
Increasing mood swings:
Yes
No
Increasing sagging muscles or breasts:
Yes
No
Increasing wrinkles:
Yes
No
Increasingly stressed:
Yes
No
Loss of concentration, sociability, activity:
Yes
No
Loss of interest in sex:
Yes
No
Muscle loss:
Yes
No
Progressive osteoporosis, decreasing bone mass or stooped posture:
Yes
No
Sagging, loose or thin skin:
Yes
No
Thinning or loss of hair:
Yes
No
Urogenital atrophy:
Yes
No
Vaginal dryness:
Yes
No
Weight loss:
Yes
No
Please use this space to explain any positive answer and write any additional information, Please also let us know the best time to contact you.

SECTION 5: ELECTRONIC SIGNATURE

This agreement between (patient) and Physician Monitored Program establishes guidelines and conditions required for the use of hormone replacement therapy (HRT) involving DEA "controlled" or” scheduled" medications. Hormone Replacement Therapy Board Certified Physician Prescribed HRT Program Solutions and (patient) agree that these guidelines and conditions are an essential factor in maintaining a successful patient/physician relationship.

Before submitting, please verify all the information is correct and print this form for your records. Patient agrees and consents to conduct business and transactions by electronic means, Electronic signature confirms authorization and agreement to the terms and conditions referenced above. This form is for pre-qualification only and a hand signed document is required for final approval by our physicians.

Today's Date:

  

Patient Signature. Type Your Name:

 (valid electronic signature)

Security Code:

(Please enter 4 digit number on left)

After Checking All Information Above is Correct (Press Right Button):

 (Click Left Button)