Please enable JavaScript in your browser to complete this form.Full NameFirstLastEmail AddressPhone NumberDate of BirthGenderMaleFemalePrefer not to sayAddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMedical History – Check all that applyHigh blood pressureDiabetesHeart DiseaseStrokeHigh cholesterolLiver diseaseKidney diseaseSleep apneaDepression or other mental health disordersThyroid disordersLow libidoErectile dysfunctionTesticular issuesCancerCurrent MedicationsRelevant Medical History apply): Gender How Known AllergiesDo you currently use:Tobacco?Alcohol?Recreational drugs?Describe your current symptoms (Check all that apply)Low sex driveErectile dysfunctionFatigueDecreased muscle massIncreased body fatDepression or mood swingsBrain fog or memory issuesSleep disturbancesDecreased motivation or driveIrritabilityHair lossWeight gainInfertility concernsWhat are your current health concerns or goals?How often do you exercise?Describe your diet?Hours of sleep per night?Stress level:LowModerateHighHave you ever had your testosterone levels checked?YesNoAre you interested in (check all that apply):General men’s wellnessWeight loss therapyTestosterone replacement therapy (TRT)Erectile dysfunction treatmentHormone optimizationPreventive health screeningAny family history of the following?Heart diseaseDiabetesHigh blood pressureCancerMental health disorderConsent and AcknowledgementI acknowledge that the information provided above is accurate to the best of my knowledge.Date / TimeDateTimeSubmit
