Complete Medical History Questionnaire

Your name *

Please initial here that you have read the above statement:*

Please select your counselor's name or choose "New Patient." Paige Monsees Damian Spalma Lauren deVaal Mike Magnetti Gerrit Blydenstein Travis Gomme Scott Gedcke Alex Beshouri Greg Lange Scott Lobel Jen Brogan-Hobbs

How did you hear about us? *  Internet  Ad  Other

Street Address

Street Address Line 2

City

Region

Postal/Zip Code

Country USA

Phone *

Email *

Birth Date: *

Driver's License Number: *

Marital Status: Married Divorced Never Married Gay

Gender  Male  Female  Transgender

Height:

Weight:

Occupation:

What are your primary goals/desires/expectations from your treatment at PRC?

Are there any of the following in the family? If any answers are checked “Yes”, please explain.  Cardiovascular disease‎  Hypertension  Breast cancer‎  Other cancers‎  Diabetes‎  Lipid disorder‎  Prostate cancer  Other illness‎

Please detail ANY of the above, including which family members were affected:

Do you smoke?  No  Yes

If “yes”, how many drinks per day and/or week?

Do you exercise?  No  Yes

If “yes”, how often?

Are you in the Military?  No  Yes

Are you a civil servant? (Police Officer, Postal Worker…)  No  Yes

Are you a current or former professional athlete?  No  Yes

Are you a current or former Olympic athlete?  No  Yes

Do you check labels for trans fat?  No  Yes

Do you use extra virgin olive oil as your primary oil?  No  Yes

Do you avoid sugar?  No  Yes

Do you avoid processed foods?  No  Yes

Do you consume water daily?  No  Yes

Do you have or have you ever had any of the following?  Cold or heat intolerance‎  Increased wrinkles‎  Decreased sex drive‎  Difficulty sleeping‎  Lack of drive‎  Sagging muscles or breasts‎  Mood swings‎  Decreased energy‎  Decreased sense of well being  Decreased testicle size‎  Decreased memory‎  Muscle loss‎  Decreased desire or ability to exercise‎  Hot flashes/flushes‎  Progressive Osteoporosis  Increased body fat‎  Loss of concentration‎  Decreased endurance  Decreased muscle strength‎  Loose or thin skin‎

Do you have or have you ever had any of the following  Vaginal dryness‎  Weight loss‎  Irregular periods  Experiencing menopause  Weight gain‎  Currently pregnant‎  PMS‎

Date of last menstrual period:

Please list ALL medications by name and dosage (including supplements); please list name of drug and your reaction to it. lastly please list hospitalizations, operations and any other significant illness with dates.:

How many hours do you sleep at night?

Lights completely off?  No  Yes

Do you turn off TV 2 hours before sleep?  No  Yes

Is it hard for you to fall asleep?  No  Yes

Do you wake up early or multiple times?  No  Yes

Are you refreshed upon waking up?  No  Yes

Would you like improvement of libido?  No  Yes

If male, would you like improvement of erection?  No  Yes

If female, would you like improvement of lubrication?  No  Yes

Do you feel good about your body image and weight?  No  Yes

Any history of car accident, head trauma (even mild jarring), etc?  No  Yes

I usually feel:

Do you have or have you ever had any of the following? If "yes" explain in area below.  Any known deficiencies‎  History of cancer‎  Chemical dependency‎  Edema or excess fluid retention‎  Genital or urinary disorders‎  Heart disease or heart attack‎  Hypertension or high blood pressure‎  Lactating  Neurological disorders  Orthopedic or muscle disorders‎  Renal or kidney disease‎  Blood disorders‎  Carpel tunnel syndrome‎  Drug allergies‎  Emotional disorders or depression  Glaucoma‎  Hyperlipidemia or high cholesterol‎  Immune disorders‎  Lung disorders‎  Endocrinological disorders‎  Poor wound healing‎  Upper respiratory problems‎

Please Explain:

I attest that I am here for age management services  YES

I attest that I am not a professional athlete  YES

I attest that I am not looking for body enhancement  YES

I attest that I am not looking for aesthetic enhancement  YES

Digital signature: I have completed the medical history form to the best of my knowledge. I certify that my answers are complete, honest and true. *