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(856) 751-2100
Email:
[email protected]
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Home
Services
Male TRT
Medical Weight Loss
Bio-Identical Hormone Replacement Therapy
Peptide Therapy
Shop
Full Script
Jan Marini
Nutrafol
Patients
New Patient Forms (Female)
New Patient Forms (Male)
Medical Weight Loss Program – Intake Form
About
About Us
Blogs
Reviews
Contact
Request Phone Call
New Patient Form (Males)
Home
New Patient Form (Males)
New Patient (FULL FORMS) - Males
Step
1
of
3
33%
New Patient Demographic Form
Please fill out the required information below. if you have any questions please feel free to call the office at (856) 751-2100.
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Age
(Required)
Height
(Required)
Weight
(Required)
Home Address
(Required)
Please input your Street Address
City
(Required)
State
(Required)
Zip Code
(Required)
Home Phone
Cell Phone
(Required)
Work
Email
(Required)
How did you hear about us?
If it's a patients name, please list it below. If other - please write below
In Case of Emergency Contact:
(Required)
Relationship
(Required)
Cell Phone
(Required)
Home Phone
Work
Symptom Checklist
Select EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE.
1. Decline in your feeling of general well-being
(Required)
(general state of health, subjective feeling)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
2. Joint pain and muscular ache
(Required)
(lower back pain, joint pain, pain in a limb, general back ache)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
3. Excessive sweating
(Required)
(unexpected/sudden episodes of sweating, hot flushes independent of strain)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
4. Sleep problems
(Required)
(difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
5. Increased need for sleep, often feeling tired
(Required)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
6. Irritability
(Required)
(feeling aggressive, easily upset about little things, moody)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
7. Nervousness
(Required)
(inner tension, restlessness, feeling fidgety)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
8. Anxiety
(Required)
(feeling panicky)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
9. Physical exhaustion / lacking vitality
(Required)
(general decrease in performance, reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, of having to force oneself to undertake activities)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
10. Decrease in muscular strength
(Required)
(feeling of weakness)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
11. Depressive mood
(Required)
(feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
12. Feeling that you have passed your peak
(Required)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
13. Feeling burnt out, having hit rock-bottom
(Required)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
14. Decrease in beard growth
(Required)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
15. Decrease in ability/frequency to perform sexually
(Required)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
16. Decrease in the number of morning erections
(Required)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
17. Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)
(Required)
1. None
2. Mild
3. Moderate
4. Severe
5. Extremely Severe
Please share any additional comments about your symptoms you would like to address
Do you have cold hands and feet?
(Required)
Yes
No
Do you have daily bowel movements?
(Required)
Yes
No
Do you have gas, bloating, or abdominal pain after eating?
(Required)
Yes
No
Please select your WEEKLY Activity Level based on this criteria
(Required)
Physical activity that accelerates heart rate / Breathlessness
0-1 day per week (Low)
2-3 days per week (Average)
More than 3 days per week (High)
Please list any prior hormone therapy?
(Required)
If None - Write NONE
Recent PSA
(Required)
If None - Write NONE
Recent Digital Rectal Exam (Date):
MM slash DD slash YYYY
Recent Rectal Exam
(Required)
Normal
Abnormal
Does Not Apply
History of Prostate problems or Biopsy. If so, please provide details
The ADAM (Androgen Deficiency in the Aging Male)
Please answer Yes or No to the following questions
Do you have a decrease in libido (sex drive)?
(Required)
Yes
No
Do you have lack of energy?
(Required)
Yes
No
Do you have a decrease in strength and endurance?
(Required)
Yes
No
Have you lost height?
(Required)
Yes
No
Have you noticed a decreased "enjoyment of life?"
(Required)
Yes
No
Are you sad and/or grumpy?
(Required)
Yes
No
Are your erections less strong?
(Required)
Yes
No
Have you noticed a recent deterioration in your ability to play sports?
(Required)
Yes
No
Are you falling asleep after dinner?
(Required)
Yes
No
Has there been a recent deterioration in your work performance?
(Required)
Yes
No
Any known drug allergies:
(Required)
Yes
No
If Yes, please explain
(Required)
Current Medications and dosage
(Required)
If None - Write NONE
Nutritional/Vitamin Supplements:
(Required)
If None - Write NONE
Current or Past Hormone Replacement Therapy:
(Required)
If None - Write NONE
Surgeries, list all and Year:
(Required)
If None - Write NONE
MEDICAL HISTORY
Please check any of the below if you have had or have
High Blood Pressure
(Required)
Yes
No
Heart Bypass
(Required)
Yes
No
High Cholesterol
(Required)
Yes
No
Hypertension
(Required)
Yes
No
Heart Disease
(Required)
Yes
No
Stroke
(Required)
Yes
No
Heart Attack
(Required)
Yes
No
Blood Clot
(Required)
Yes
No
Pulmonary Embolism
(Required)
Yes
No
Arrhythmia
(Required)
Yes
No
Hepatitis
(Required)
Yes
No
HIV
(Required)
Yes
No
Lupus
(Required)
Yes
No
Auto-Immune DIsease
(Required)
Yes
No
Fibromylagia
(Required)
Yes
No
Trouble Passing Urine OR Take Flomax or Avodart
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Chronic Liver Disease
(Required)
Yes
No
Thyroid Disease
(Required)
Yes
No
Arthritis
(Required)
Yes
No
Depression/Anxiety
(Required)
Yes
No
Psychiatric Disorder
(Required)
Yes
No
Cancer Of Any Type
(Required)
Yes
No
Cancer Type - Please Write Below
(Required)
CAPTCHA
(856) 751-2100
[email protected]
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