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CHIEF COMPLAINT
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C/C - Body
• • •
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C/C - Psychology:
• • •
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C/C - Intimacy
• • •
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C/C - Skin & Hair
• • •
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C/C - Musculoskeletal
• • •
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Miscellaneous:
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HISTORY OF PRESENT ILLNESS
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History Present Illness:
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Problem List length of time:
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HPI - Severity
• • •
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PMHx/PSx/Allergies
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Past Medical History
• • •
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Past Medical History Freewrite
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Past Surgical History
• • •
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Past Surgical History Freewrite:
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Medication/Food Allergies
• • •
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Allergies Other:
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Miscellaneous
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Subjective- Daily Activity
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Subjective - Sleep:
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Subjective- Water:
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Subjective- Time of Exercise:
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Subjective- Hours of Excercise per Week:
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Other:
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Subjective- Metabolic Activity
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Subjective- Energy Levels:
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Subjective- Concentration Levels:
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Subjective- Stress Levels:
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Subjective- Libido Levels:
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Other:
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OBJECTIVE
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Physical Exam
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Physical Exam
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Telemedicine Visit
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Other:
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DISCLOSURES
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Patient Treatment and Partnership Discussion
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Hormone Therapy Disclosure
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Laboratory Essentials
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Assesment
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Miscellaneous
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Plan:
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Wellness Plan
• • •
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Plan Details
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Plan Details
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Follow Up
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Personalized Treatment Protocol
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Insulin Sensitizers/Stabilizers
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Cholesterol Lowering Supplements
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B-12/B-Complex Supplementation
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Vitamin D-3 Supplementation
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Thyroid Support/Supplementation
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B-12/B-Complex Supplementation
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DHEA Supplementation
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Pregnenolone Supplementation
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Growth Hormone/Peptide Supplementation
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Melatonin Supplementation
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Intermittent Fasting
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Anit-Inflammatory Diet
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Training/Workout
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HCG Weight Loss Program
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Peptide Therapy
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Longevity Program
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Intermittent Fasting
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