General Information
First Name
Last Name
Email
*
Phone
*
Date of birth
Sex assigned at birth
Height (inches)
Weight (in Ibs)
How did you hear about us
Address
Street Address
City
State
Country
Country
Postal Code
What Can We Support You With?
Select the symptoms or concerns you’re currently experiencing so we can better understand your needs and provide tailored recommendations.
Low energy / fatigue
Trouble sleeping
Mood changes (irritability, anxiety, low mood)
Brain fog / poor focus
Low sex drive or performance issues
Weight gain or difficulty losing weight
Loss of muscle or strength
Hair thinning or loss
Skin or aging concerns (wrinkles, elasticity)
Hot flashes / night sweats (women)
Enlarged prostate / urinary issues (men)
Joint or muscle aches
Frequent illness / slow recovery
Blood pressure, cholesterol, or circulation concerns
Sugar or carb cravings / weight around midsection
Do you have thoughts that you would be better off dead or of hurting yourself in some way?
Yes
No
Feeling down, depressed, or hopeless
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious, or on edge
Not at all
Several days
More than half the days
Nearly every day
Are you currently taking any Selective Serotonin Reuptake Inhibitors (SSRIs) or Serotonin Norepinephrine Reuptake Inhibitors (SNRIs), such as escitalopram (Lexapro), sertraline (Zoloft), paroxetine (Paxil), fluoxetine (Prozac), or venlafaxine (Effexor)?
Yes
No
Treatment Preferences
Please select your preferred treatment options
*
Injectable
Cream
Current Hormone Treatment
Are you currently using any hormone treatments?
*
Yes
No
Allergies & Medications
Please list your current medications and supplements, including any medications taken for anxiety or depression.
*
Please list all Allergies: Medication, Food, Seasonal or other.
*
Email:
[email protected]
Phone : (561) 407-7983
Address : 5458 Town Center Road
