Male – Evaluation Intake Form

Todays Date

First Name

Last Name

Email

Phone

Date of Birth

Height

Weight

Occupation

Do you use tobacco, CBD or THC? If yes, how often and how much?

Do you use alcohol? If yes, how often and how much?

Do you use caffeine? If yes, how often and how much?

Do you exercise? If yes, what type of exercise and for how long have you been exercising?

How many hours of sleep do you typically get per night and are they uninterrupted? If they're interrupted, what time and for what reason (children, night shift, health concerns, etc)

Do you wake rested or tired (even when getting 7-8 hours of sleep?)

What would you like to change about your current dietary choices?

Allergies:

Please list any allergies and describe the reaction that occurred.

Drugs

Food

Other

Medical Conditions/ Diseases:

Please list any conditions/diseases that you have been diagnosed with or suffer from. (Examples include heart disease. high blood pressure, depression, ulcers, arthritis, insominia, etc.)

Family History

Choose all that apply
Cardiovascular DiseaseDiabetes MellitusBenign Prostatic Hyperplasia (Enlarged Prostate)OsteoporosisCancerBlood Clotting DisordersNone of the Above

If you checked yes to any of the conditions above, please elaborate.

Over-the-Counter Medication History:

Please list all the non-prescription medications that you are taking. (Include vitamins, herbals, and supplements): *

Current Prescription Medications:

Please list all the current prescription medications you're taking. Include name and strength, date started, how often per day, and medical condition being treated

Please list all hormones previously or currently taken. Include name, date started, date stopped, and reason for taking them. *

What is your primary goal for taking hormone replacement therapy?*