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Specialized Therapies:
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* Hormone Optimization
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LIFE ENHANCEMENT CLINICS OF MONTANA
Your Destination for Renewed Vitality!
Health History & Symptoms
Male Biote Dosing Info
First Name
*
Last Name
*
Phone
*
Email
*
Today's Date
*
Date of birth
Age
Height:
*
Current Weight
*
Have you been diagnosed with any cancer since initial pelleting? (excluding basal cell carcinoma)?
*
YES
NO
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Blood Clot, DVT, heart attack or stroke since last pelleting?
*
YES
NO
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List is empty.
Any changes in your medical conditions since your last pelleting?
*
Any changes in your medications since your last pelleting?
*
Male Patient Questions (select all that apply)
*
I am currently trying to conceive or wish to do so in the future
I want to maintain fertility
I am on 5-alpha reductase inhibitor (prostate medication)
I am on a PDE-5 Inhibitor (Cialis, Viagra, Etc.)
I am currently partaking in Testosterone Replacement Therapy?
I am on other testosterone boosting medication (Clomid, HCG, etc.)?
I am currently partaking in Thyroid Replacement Therapy?
I am currently on statins?
I am a smoker?
I am currently on oral nitrates?
NONE of the Above
Cardiovascular Conditions: (select all that apply)
*
Heart Attack or Stroke (within 6 months)
Tachycardia
DVT or Blood Clot (within last 6 months)
Hypertension
Hyperlipidemia
Obstructive Sleep Apnea
Atrial Fibrillation
Patient Takes Anticoagulant Medication
NONE of the Above
Neurological/Endocrine/Metabolic (select all that apply)
*
Epilepsy or Seizure Disorder
Depression/Anxiety
Psychiatric Conditions
Migraine with Aura
Meningioma
Diabetes Type 2 or Insulin Resistance
Hyperthyroid
Hypothyroid
Multiple Endocrine Neoplasia Type-2
NONE of the Above
Autoimmune Conditions (select all that apply)
*
Diabetes Type 1
Hashimoto’s Thyroiditis
Graves’ Disease
Rheumatoid Arthritis
Multiple Sclerosis
Systemic Lupus (Erthematosus)
Psoriasis
Positive ANA
IBS (Irritable Bowel Syndrome)
Crohn’s Disease
Ulcerative Colitis
NONE of the Above
Organ Specific Conditions (Males) (Select all that apply)
*
Liver Disease or History of Liver Disease
Kidney Disease or History of Kidney Disease
LAM (Lymphangioleimyomatosis)
Osteoporosis or Osteopenia
Prostate Enlargement (BPH)
HIV
Hepatitis
Hemochromatosis
Pancreatitis or History of Pancreatitis
History of or Gall Bladder Disease
Polycythemia Vera (PV)
NONE of the above
Male Symptoms & Concerns (Select all that apply)
*
Acne
Erectile Dysfunction (ED)
Decreased Libido
Decreased Desire
Inability to or delayed Orgasm
Weight Gain
Decreased Muscle Mass
Difficulty Sleeping
Urinary Incontinence
Dry or Flaking Skin
Lack of Energy (Fatigue)
Decrease in Strength or Endurance
Decrease in Work Performance
Frequent Urinary Tract Infections
Brittle Nails
Thinning Eyebrows
Hair Thinning
Cold Hands or Feet
Mind Racing at Bedtime
Eating When Stressed
Mood Swings
Gynecomastia
Abdominal Obesity
NONE of the above
Verification Statement
*
The above information is true to the best of my knowledge.
Patient Signature
*
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