Consultation Form

First Name *

Last Name *

Phone *

Email Address *

Street Address *

Address Line 2

City

State

Zip Code

Date of Birth *

Gender *

Male

Female

What is your height? *

What is your weight? *

First Name *

Last Name *

Friend or family member's name

What radio station?

What were you searching for?

Where else did you find us?

Weight Loss Program

Please list your top 5 reasons for weight loss

Do you have a history of cancer (current or past)?

Yes

Type of cancer

Diagnosis date

Remission date

Are you pregnant?

Yes

Possible

N/A

Periods are?

Regular

Irregular

None

N/A

Hysterectomy?

Full

Partial

N/A

Both ovaries removed?

Yes - Both

Yes - Only one

Endometriosis?

Yes

Fibroids?

Yes

Date of last Mammogram

Date of last Pap Smear

Do you have any of the following?

Do any of your family members have a history of blood clots or a blood clotting disorder?

Yes

Have you had a blood clot?

Yes

Have you had any surgical procedures?

Yes

Please list surgical procedures

Do you take any medications?

Yes

List of medications

Do you take any supplements?

Yes

List of supplements

Do you have any allergies or sensitivities?

Yes

List of allergies or sensitivities

Do any of your family members have any medical conditions?

Yes

Please list family medical history

Hormone Information

Nutrition Guidance

Are you interested in learning more about our Nutrition Guidance Program? If so, which areas?

Preferred Pharmacy

Pharmacy Name

Pharmacy Address

City

State or Province

Zip or Postal Code

Pharmacy Phone

Peptide Therapy Medical History

Yes to any of these questions is a possible contraindication and will be reviewed by a provider.

Please provide more information on the history of cancer

Hormones	Weight Loss	Food Sensitivity Testing
IV Therapy	Sexual Medicine	Peptide Therapy
Other

Get-Up-And-Go	Recovery & Performance	Myer's Cocktail
Immunity	Alleviate	Inner Beauty
NAD+ (250mg or 500mg)	Vitamin C (Regular 5g)	High-Dose Vitamin C (25g-75g)
Amino Blend Injection	B12 Injection	Magnesium Injection

Anemia	ADD/OCD	Anxiety
Arthritis	Asthma	Bleeding disorder
Cancer	(CHF)Congestive heart failure	COPD
Coronary artery disease	Depression	Diabetes
Diverticulitis	Emphysema	Gastritis
Gout	Heartburn/reflux	Hepatitis
Hiatal hernia	High blood pressure	High cholesterol
High triglycerides	HIV/AIDS	H‐pylori
Incontinence	Irregular heart beat	Irritable Bowel
Kidney disease	Kidney stones	Liver disease
Migraines/Headaches	Polycystic Ovarian Syndrome (PCOS)	Previous heart attack
Prostate problems	Pulmonary Edema	Rheumatic fever
Sleep apnea / snoring	Stent placed	Stomach ulcers
Stress urinary incontinence	Stroke/TIA/seizure	Substance abuse
Thyroid problems	Tuberculosis	NONE OF THE ABOVE

Anemia	ADD/OCD	Anxiety
Arthritis	Asthma	Bleeding disorder
Cancer	COPD	Depression
Diabetes	Diverticulitis	Emphysema
Gastritis	Gout	Heartburn/reflux
Hepatitis	Hiatal hernia	High blood pressure
High cholesterol	High triglycerides	HIV/AIDS
H‐pylori	Incontinence	Irregular heart beat
Irritable Bowel	Kidney disease	Kidney stones
Liver disease	Migraines/Headaches	Polycystic Ovarian Syndrome (PCOS)
Prostate problems	Rheumatic fever	Sleep apnea / snoring
Stomach ulcers	Stress urinary incontinence	Substance abuse
Thyroid problems	Tuberculosis	NONE OF THE ABOVE

(CHF)Congestive heart failure	Coronary artery disease	Previous heart attack
Pulmonary Edema	Stent placed	Stroke/TIA/seizure
NONE OF THE ABOVE

Protein-C Deficiency	Protein-S Deficinecy	Anti-Thrombin III Deficiency
Factory 5 Liden Deficiency	G6PD Deficiency	NONE OF THE ABOVE

Aches and pains	Anxiety	Apathy
Autoimmune Illness	Bone loss	Brittle nails
Chronic Illness	Cold body temperature	Decreased libido
Decreased mental sharpness	Decreased muscle mass	Decreased stamina
Decreased urine flow	Decreased sexual satisfaction	Depression
Elevated cholesterol	Elevated triglycerides	Erectile dysfunction
Fibromyalgia	Foggy thinking	General Fatigue
Hair loss	Headaches	Hot flashes
Inability to lose weight	Increased urinary urge	Infertility problems
Irregular Menstruation	Irritability	Lack of motivation
Morning Fatigue	Night Sweats	Oily Skin
Painful intercourse	Prostate problems	Sleep disturbances
Susceptible to infections	Vaginal Dryness	Weight gain in waist
NONE OF THE ABOVE	Other (list below)

Not Interested	General Nutrition	PCOS Management
Diabetes / Pre-Diabetes	Disease Prevention	Other

CJC 1295 + Ipamorelin	BPC-157	PT 141
Kissepeptin	Semaglutide	Not sure just yet

History of Pituitary Abnormalities?	History of Pancreatitis?	History of Cancer?
Are you less than 25 years old?	None of the Above