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Specialized Therapies:
* Joint Repair
* Hormone Optimization
* Peptides
LIFE ENHANCEMENT CLINICS OF MONTANA
Your Destination for Renewed Vitality!
New Patient Intake Health History Form
MALE PATIENTS
First Name
*
Last Name
*
Phone
*
Address
City
State
Zip
Email
*
Treatments of Interest (select all that apply)
*
Nervous System Optimization
Regenerative Joint Health Repair
Hormone Optimization
Medical Weight Loss
Preferred Clinic Location:
*
Bozeman
Billings
Helena
Missoula
Today's Date
Birth Date
*
Occupation
How did you hear about us?
Marital Status
Single
Married
Divorced
Living with a Partner
Widow
Emergency Contact Name & Phone #
Emergency Contact
Do you currently have active cancer and/or are you currently treating cancer?
*
Yes
No
Tell us more about your cancer/treatment if applicable:
What is the #1 health issue you'd like us to address?
*
What have you done to treat the above problems?
Have your symptoms Improved, Stayed the Same or Gotten Worse with treatment?
Improved
Stayed the same
Gotten Worse
What makes your condition Worse?
What makes your condition Better?
What activities do you love doing?
Overall Health/Nerve Optimization
OVERALL HEALTH & NERVE ISSUES ( click all that apply)
*
Headaches
Dizziness
Sinus problems
Sciatica/Pinched Nerves
High Stress
Car Accidents
Broken Bones
Work Accidents
Colon problems (constipation/diarrhea)
Heart/circulation issues
Stomach/Reflux
Chronic liver disease (hepatitis, fatty liver, cirrhosis)
Lung problems/Asthma
Thyroid disease
Kidney problems
Liver problems
Rheumatoid Arthritis
Peripheral Neuropathy
Smoker (cigarettes, cigars, e-cigs, marijuana)
Consume Alcohol
Consume Caffeine
NONE of the Above
List any Prescription Drugs you are currently taking:
List any Supplements you are currently taking
List all Allergies:
List all Surgeries that you have had:
Numbness or Tingling
If Yes, where is the numbness or tingling? (If None, type NA)
REGENERATIVE JOINT HEALTH ISSUES (click all that apply): 53dmg
*
Arthritis
Neck Pain
Jaw/TMJ Pain
Mid Back Pain
Scoliosis
Low Back Pain
NONE OF THE ABOVE
Shoulder Pain ?
None
Left
Right
Both
Arm, Elbow, Wrist or Hand Pain ?
None
Left
Right
Both
Hip Problems ?
None
Left
Right
Both
Leg Problems ?
None
Left
Right
Both
Knee Problems ?
None
Left
Right
Both
Foot/Ankle Problems ?
None
Left
Right
Both
Hormone Health
Hormone Optimization Section
*
Current Weight
Goal Weight
Biote Health History Males (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 on other testosterone boosting medication (Clomid, HCG, etc.)?
I am currently on statins?
I am a smoker?
I am currently on oral nitrates?
I am currently partaking in Testosterone Replacement Therapy?
I am currently partaking in Thyroid Replacement Therapy?
NONE of the Above
If on testosterone or thyroid therapy, list type and current dosing levels
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
Cancer (male)
*
Breast Cancer or History of Breast Cancer
Active Prostate Cancer or History of Prostate Cancer
Thyroid Cancer or History of Thyroid Cancer
Except for Basal Cell Carcinoma, Any Other Cancers?
None of the above
Neurological and Endocrine/Metabolic Conditions (select all that apply)
*
Epilepsy or Seizure Disorder
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)
*
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
*
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
Semaglutide Contraindications (check all that apply)
Thyroid Tumors
Acute Pancreatitis
Acute Gallbladder
Hypoglycemia
Type 1 Diabetes
Currently taking insulin
Kidney Injuries
Hypersensitivity
Diabetic Retinopathy
Increased Heart Rate
Suicidal Behavior
NONE of the Above
Other symptoms or unique health circumstances to take into consideration
Verification Statement
*
The information provided is accurate & true to the best of my knowledge
Signature
*
Clear
