Intake — Elite HRT

Personal information

Tell us a little about yourself.

First Name * Required

Last Name * Required

Email * Valid email required

Date of Birth * Required

Gender * Required

Driver's License #

Weight (lbs) * Required

Height * Required

Contact details

How and when can we best reach you?

Address * Required

Home Phone

Home — Best Time to Call

Work Phone

Work — Best Time to Call

Cell Phone * Required

Cell — Best Time to Call

Occupation

Lifestyle & consultant

Help us understand your background and habits.

Have you already contacted Elite HRT? If yes, name of your wellness consultant:

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

Do you exercise?

Yes No

Do you take supplements?

Yes No

Social History

Smoking and/or drinking frequency. Exercise type and frequency. Type of supplements and dosages.

Medical history — part one

Check any conditions that apply to you.

Select all that you currently have or have had in the past.

Medical history — part two

Continue checking any conditions that apply.

Explain the history of any conditions or diseases checked above

List all medications you are taking (Name, Dosage). Type "NONE" if not applicable.

Prior history & physician

Have you had HRT or related therapies before?

Prior history of HRT, steroid, or other hormone use?

Do you have prior medical records / labs available?

Yes No

Date of Last Physical Exam

Physician's Name

Physician's Phone

Family health history

Check any conditions present in your immediate family.

Cardiovascular Disease Diabetes, Thyroid or Other Endocrine Disorder Hypertension Lipid Disorder Prostate Cancer Other Forms of Cancer Other Illnesses

Explain Family Health History

Current symptoms

Check any symptoms you are currently experiencing.

This helps us understand which therapies may be most beneficial. Check all that apply.

Final details & signature

Almost done. Just a few last items.

Currently Pregnant?

Yes No N/A

Other Conditions Not Listed

Additional Information

Anything else you'd like us to know.

Digital Signature *

Please print your full name to confirm.

Required

I confirm that the information provided above is accurate and complete to the best of my knowledge.

Patient intake

Personal information

Contact details

Lifestyle & consultant

Medical history — part one

Medical history — part two

Prior history & physician

Family health history

Current symptoms

Final details & signature