Call : (856) 751-2100
Email: [email protected]
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Next Level Health at Virapel
  • Home
  • Services
    • Male TRT
    • 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

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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)
MM slash DD slash YYYY
Please input your Street Address
If it's a patients name, please list it below. If other - please write below

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)
2. Joint pain and muscular ache(Required)
(lower back pain, joint pain, pain in a limb, general back ache)
3. Excessive sweating(Required)
(unexpected/sudden episodes of sweating, hot flushes independent of strain)
4. Sleep problems(Required)
(difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)
5. Increased need for sleep, often feeling tired(Required)
6. Irritability(Required)
(feeling aggressive, easily upset about little things, moody)
7. Nervousness(Required)
(inner tension, restlessness, feeling fidgety)
8. Anxiety(Required)
(feeling panicky)
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)
10. Decrease in muscular strength(Required)
(feeling of weakness)
11. Depressive mood(Required)
(feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use)
12. Feeling that you have passed your peak(Required)
13. Feeling burnt out, having hit rock-bottom(Required)
14. Decrease in beard growth(Required)
15. Decrease in ability/frequency to perform sexually(Required)
16. Decrease in the number of morning erections(Required)
17. Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)(Required)
Do you have cold hands and feet?(Required)
Do you have daily bowel movements?(Required)
Do you have gas, bloating, or abdominal pain after eating?(Required)
Please select your WEEKLY Activity Level based on this criteria(Required)
Physical activity that accelerates heart rate / Breathlessness
If None - Write NONE
If None - Write NONE
MM slash DD slash YYYY
Recent Rectal Exam(Required)

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)
Do you have lack of energy?(Required)
Do you have a decrease in strength and endurance?(Required)
Have you lost height?(Required)
Have you noticed a decreased "enjoyment of life?"(Required)
Are you sad and/or grumpy?(Required)
Are your erections less strong?(Required)
Have you noticed a recent deterioration in your ability to play sports?(Required)
Are you falling asleep after dinner?(Required)
Has there been a recent deterioration in your work performance?(Required)
Any known drug allergies:(Required)
If None - Write NONE
If None - Write NONE
If None - Write NONE
If None - Write NONE

MEDICAL HISTORY

Please check any of the below if you have had or have
High Blood Pressure(Required)
Heart Bypass(Required)
High Cholesterol(Required)
Hypertension(Required)
Heart Disease(Required)
Stroke(Required)
Heart Attack(Required)
Blood Clot(Required)
Pulmonary Embolism(Required)
Arrhythmia(Required)
Hepatitis(Required)
HIV(Required)
Lupus(Required)
Auto-Immune DIsease(Required)
Fibromylagia(Required)
Trouble Passing Urine OR Take Flomax or Avodart(Required)
Diabetes(Required)
Chronic Liver Disease(Required)
Thyroid Disease(Required)
Arthritis(Required)
Depression/Anxiety(Required)
Psychiatric Disorder(Required)
Cancer Of Any Type(Required)
Next Level Health at Virapel

At Next Level Health at Virapel, we're dedicated to helping you achieve your wellness goals with personalized care and cutting-edge treatments.

Hours of Operation

Monday: 9 am - 4 pm
Tuesday: 9 am - 7 pm
Wednesday: 9 am - 5 pm
Thursday: 9 am - 5 pm
Friday - Sunday: Closed

Contact

602 Sheppard Rd, Voorhees
Township, NJ 08043

[email protected]

(856) 751-2100

Website Designed by IL Webdesign

(856) 751-2100
[email protected]
Book Appointment
Next Level Health at Virapel
Denounce with righteous indignation and dislike men who are beguiled and demoralized by the charms pleasure moment so blinded desire that they cannot foresee the pain and trouble.

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