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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:
REGENERATIVE JOINT HEALTH ISSUES (click all that apply)
*
Arthritis
Neck Pain
Jaw/TMJ Pain
Mid Back Pain
Scoliosis
Low Back Pain
NONE OF THE ABOVE
Numbness or Tingling ?
If Yes, where is the numbness or tingling? (If None, type NA)
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
Decline in your feeling of general well-being (general state of health, subjective feeling)
*
None
Mild
Moderate
Severe
Extremely Severe
Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache)
*
None
Mild
Moderate
Severe
Extremely Severe
Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain)
*
None
Mild
Moderate
Severe
Extremely Severe
Sleeping Problems (difficulty in falling asleep, difficulty in sleelping thru the night, waking up early, feeling tired, poor sleep, sleeplessness)
*
None
Mild
Moderate
Severe
Extremely Severe
Increased need for sleep, often feeling tired
*
None
Mild
Moderate
Severe
Extremely Severe
Irritability (feeling aggressive, easily upset about little things, moody)
*
None
Mild
Moderate
Severe
Extremely Severe
Nervousness (inner tension, restlessness, feeling fidgety)
*
None
Mild
Moderate
Severe
Extremely Severe
Physical exhaustion / lacking vitality (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)
*
None
Mild
Moderate
Severe
Extremely Severe
Decrease in muscular strength (feeling of weakness)
*
None
Mild
Moderate
Severe
Extremely Severe
Depressive Mood (feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use)
*
None
Mild
Moderate
Severe
Extremely Severe
Feeling that you have passed your peak
*
None
Mild
Moderate
Severe
Extremely Severe
Feeling burnt out, having hit rock-bottom
*
None
Mild
Moderate
Severe
Extremely Severe
Decrease in beard growth
*
None
Mild
Moderate
Severe
Extremely Severe
Decrease in ability/fequency to perform sexually
*
None
Mild
Moderate
Severe
Extremely Severe
Decrease in the number of morning erections
*
None
Mild
Moderate
Severe
Extremely Severe
Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)
*
None
Mild
Moderate
Severe
Extremely Severe
Please share any additional comments about your symptoms you would like to address.
Do you have cold hands and feet?
*
Yes
No
Do you have gas, bloating or abdominal pain after eating?
*
Yes
No
Please select your WEEKLY Activity Level based on this criteria: Physical activity that accelerates heart rate / Breathlessness
*
0-1 days/week (low)
2-3 days/week (average)
More than 3 days/week (high)
Please list any prior hormone therapy?
GLP-1 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
Verification Statement
*
The information provided is accurate & true to the best of my knowledge
Signature
*
Clear
