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Allergies
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Annual Physical Exam
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Anxious
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Asthma
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Attention Problems
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Back Problems
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Cough
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Cold
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Dizzy
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Depression
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Diabetes
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Earache
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Facial Questions
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gastrointestinal problem
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fatigue
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Heartburn
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Hypertension
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Difficulty Breathing
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Headache
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Difficulty Swallowing
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Neck Pain
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Difficulty Urinating
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Fever
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Facial Pain
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Extremity pain
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Turn on this switch, Checklist for Men
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Turn on this switch, Checklist for Women
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Decline in general well being
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Joint pain/muscle ache
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Excessive sweating
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Sleep problems
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Increased need for sleep
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Irritability
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Nervousness
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Anxiety
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Depressed mood
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Exhaustion/lacking vitality
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Declining Mental Ability/Focus/Concentration
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Feeling you have passed your peak
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Feeling burned out/hit rock bottom
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Decreased muscle strength
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Weight gain/Belly Fat/Inability to Lose Weight
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Breast Development
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Shrinking Testicles
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Rapid Hair Loss
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Decrease in beard growth
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New Migraine Headaches
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Decreased desire/libido
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Decreased morning erections
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Decreased ability to perform sexually
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Infrequent or Absent Ejaculations
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No Results from E.D. Medications
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Other symptoms that concern you:
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Depressed mood
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Memory Loss
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Mention Confusion
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Decreased sex drive/libido
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Sleep problems
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Mood changes/Irritability
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Tension
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Migraine/severe headaches
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Difficult to climax sexaully
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Bloating
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Weight gain
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Breast tenderness
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Vaginal dryness
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Hot flashes
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Night sweats
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Dry and Wrinkled Skin
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Hair is Falling Out
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Cold all the time
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Swelling all over the body
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Joint pain
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Other symptoms that concern you:
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Please click on FREEDRAW
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PERSONAL HISTORY
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How were you referred to us?
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Do you regularly sun bathe/use tanning salons?
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How often?
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MEDICAL HISTORY
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Currently under the care of a physician?
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If yes, for what?
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Do you have any of the following -->
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Medical conditions
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Any other health problems/medical conditions?
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If yes, please list
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Have you ever had an allergic reaction?
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List any and all that you have had and -->
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--> describe the reaction you experienced
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Allergic reaction
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Others
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Reactions
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MEDICATIONS
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Oral prescription medications you are taking?
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Birth control pills
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Hormones
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Others
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<-- It is required that you list all of them
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Do you take any medications for heart conditions
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If yes, please list
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Are you on any -->
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Mood altering or anti-depression medication?
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Topical medications/creams you currently use
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RetinA
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Herbal supplements you use regularly?
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HISTORY
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FOR OUR FEMALE CLIENTS ONLY
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Are you pregnant?
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Are you trying to become pregnant?
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Are you breastfeeding?
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Are you using contraception?
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Consent
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