HRT Medical History/Lifestyle Questionnaire & Lab Ordering Form

Medical History/Lifestyle Questionnaire

&

Lab Ordering Form

Please Note: After completing this form you will receive correspondence within 48-72 hours from the physician about STEP 2: scheduling the lab testing & physical exam.

*Denotes Required Fields
General Information: Part 1
Full Name *

First Name Last Name
Gender *

Male Female
Marital Status *
Birth Date *

Month Day Year

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail Address *
Home Phone *

- Area Code Phone Number
Mobile Phone
Receive TEXT/SMS *
Emergency Contact Name *
Emergency Contact Relationship *
Emergency Contact Phone *
Referred by *
Goals: Part 2
Please check all service/products you are interested in: *

Bio-Identical Hormone Replacement Thyroid Therapy Adrenal Therapy Weight Loss with HCG Weight Loss without HCG Sexual Enhancement B12 Injections or other Vitamin Injection Therapies Nutrition Therapy
Please list any other services/products you are interested in that are not listed above? *
What made you decide to use our services/products? *
What are your over-all age management goals? *
Do you consider yourself overweight? *
Are you interested in losing weight? *

Yes No
What is your current height? *
What is your current body weight? *
If looking to lose weight what is your goal body weight? *
Are you interested in losing body fat but remain close to your current weight? *

Yes No
What size dress (females) or pants (males) do you wear? *
If applicable what is your GOAL size dress (females) or pants (males) you are trying to get down to? *
What are your major problem area(s) you are concerned about? *
How soon are you looking to fix these problem areas? *
Do you want feel and look younger ? *
Do you want more energy? *
Do you want to have more motivation and be in a better mood? *
Do you want to gain muscle? *
Are you just looking to “tone up” your body? *
Do you want to tighten skin on your body? *
Do you want to tighten skin on your neck/face? *
Do you want to lose cellulite? *
Do you want to clear up skin issues? *
Do you want to fix hair thinning issues? *
Do you want to fix sexual dysfunction issues? *
Medical History/Lifestyle: Part 3
Please check all that apply: *

I have/had cancer I have liver disease I have kidney disease I have type 1 diabetes I have type 2 diabetes I have heart disease I have high blood pressure I have high cholesterol I have a mind disorder (depression, anxiety, panic attacks, etc.) I have arthritis I have an autoimmune disease I have a bowel disease I have epilepsy or another seizure related disease I have surgical implants (cosmetic or health related) I have HIV / AIDS I have an infection (viral, bacterial, fungal, etc.) None apply
If you have any of the current conditions above or you had any of them in the past? (please explain): *
Have you had your gallbladder removed? If Yes, when? *
Please list any other current health problems, conditions or diseases: *
Please list all surgeries (cosmetic or health related): *
Are you currently on hormone replacement therapy? *
If on hormone replacement medication, please list what type(s) and the dosage? *
When was the last date you had your hormones tested? *
Are you currently on thyroid medication? *
If on thyroid medication, please list what type(s) and the dosage? *
When was the last date you had your thyroid tested? *
Have you ever had your thyroid anti-bodies tested? *
Do you have Hashimoto's thyroiditis? *
Do you have Grave's disease? *
Please check all that apply (T): *

I have a low body temperature I have a high body temperature I have low and high body temperature I have cold hands and feet I have dry and brittle hair, skin and nails I have memory lapses and poor concentration I gain weight easy I can't drop weight even if I diet and exercise I have a puffy face/neck I feel fatigued/exhausted often None Apply
Please check all that apply (C): *

I have regular aches and pains I am regularly irritable I crave sugars/sweets I have allergies I regularly get heart palpitations I have sleep disturbances I get regular headaches I feel stressed regularly I crave salt I feel fatigued/exhausted often None Apply
Have you ever had your Vitamin D levels tested? If Yes, what were your results? *
Do you have regular daily bowel movements? If No, please explain: *
Do you regularly get bloated after eating? If Yes, please explain: *
Please list any medications you are currently taking and the reason: *
Please list any supplements you are currently taking: *
Please list your regular sleep habits: *
Do you regularly go to bed before 11pm? *
Do you regularly get 6 hours of sleep each night? *
Is it difficult for you to fall asleep? *
Is it difficult for you to stay asleep? *
Is it difficult for you to wake up in the morning? *
Are you regularly fatigued during the day? (please explain) *
Please list your regular exercise habits: *
Please describe your current dietary habits: *
Are you gluten or lactose intolerant? *
Do you consume sugar daily? *
Do you eat fruit daily? *
Are you currently on a weight loss program or diet? *
How many ounces of water do you drink daily? *
How many servings of caffeine do you have daily? *
How much alcohol do you drink? *
Do you smoke? *
Males ONLY
Please check all that apply:

Decrease mental ability (focus, memory, etc.) Low sex drive Decrease erection quality Depressed motivation and mood Decreased muscle mass Increase body fat (love handles, spare tires, etc.) Decreased stamina Hair loss Increase urinary urge Decrease urinary output Increase triglycerides Hemochromatosis None Apply
Do you have known prostate problems? If Yes, please explain:
Are you interested in quickly increasing erection strength?
Are you interested in non-surgical penile enlargement?
Females ONLY
Women, please list your last date of menstruation:
Do you no longer have a menstrual cycle?
Are your menstrual cycles heavy?
Are your menstrual cycles light and spotty?
Are your menstrual cycles irregular?
Do you get PMS symptoms regularly?
Do you get constipated around your menstrual cycles?
Do you have PCOS (Polycystic Ovary Syndrome)?
Have you had a hysterectomy?
Are you possibly pregnant?
Have you ever given birth?
Have you given birth in the last 6 weeks?
Are you currently breastfeeding?
Please check all that apply:

Decrease mental ability (focus, memory, etc.) Low sex drive Vaginal dryness and/or pain during sex Depressed motivation and mood Decreased muscle mass Increase body fat (hips, belly, arms, back, etc.) Frequent urinary tract infections Hair loss Incontinence Breast pain/tenderness Fibroids and/or cysts Endometriosis Lichen sclerosis Hot flashes Decreased bone density Anemia None Apply
Please list any other female problems that you may have that are not listed above:
Are you interested in non-surgical vaginal tightening/re-shaping?
Are you interested in minimally invasive PRP/Fat Transfer body contouring and/or breast augmentation?
Comprehensive Laboratory Tests Ordering: Part 4
STEP 1 - Choose Your Complete HRT Lab Testing Panel:

FEMALE Complete HRT Panel - $385 MALE Complete HRT Panel - $385
STEP 2 - Choose Add-On Testing: *

Vitamin D - 25 - hydroxy - $60 Serum Magnesium - $30 None
Please note: On some occasions, the consulting licensed physician may require you to get one or more of the add-on options and/or other additional lab testing based on your medical history and/or initial laboratory results, in order for you to receive the best possible care. This may be determined before you receive your initial laboratory requisition or after you recieve your initial laboratory results. (Complete HRT Panels include Free & Total Testosterone, DHEA-s, Estradiol, Thyroid (TSH, Free T3, Free T4), Progesterone (female only), PSA (males only) and CBC/Chemistry/Lipids.)
Step 3 - Payment Information (choose one): *

Credit Card Debit Card
Credit/Debit Card Information
Name on Card *
Type of Card *
Full Card Number *
Last 4 digits of the Card Number *
3 digit visa, MC, discover or 4 digit AMEX security code *
Expiration Date *

- Month - Day Year
I agree to HRT Centers of America LLC to charge my payment source above for the agreed upon services and/or products signified above. I UNDERSTAND THAT ALL SALES FOR SERVICES AND/OR PRODUCTS ARE FINAL. I understand that I have 60 days (from the date of this form) to complete my services purchased, otherwise I have to completely forfeit these services nor will I receive a refund for any unused services. I will not dispute the HRT Centers of America LLC's billing with my debit or credit card company; so long as the transactions correspond to the exact services and/or products I signified above.
*

I have read and agree to the above
Liability Waiver: Part 5
I understand HRT Centers of America LLC does not practice medicine. I understand that HRT Centers of America LLC is a management service organization that received my request for a physician consultation and, in turn, a Licensed physician will review and respond.The physician who reviews my medical history, physcial examination and labwork, is who makes the medical determination about what medications and/or nutrients are best for me. Medications and/or nutrients are not guaranteed to be prescribed, as it is up to the physician based on medical necessity. I understand HRT Centers of America LLC does not direct,control or influence the treatment decisions made by the Consulting Licensed Physician with respect to my care. HRT Centers of America LLC is not liable for any negligent act or omission of the Consulting Licensed Phsician. I understand that my medical records become sole property of the Consulting Licensed Physician and copies may be made available to HRT Centers of America LLC.
*

I have read and agree to the above
The Licensed Physician reviewing my Lifestyle Questionnaire/Medical History will make a decision based upon my honest responses in making his or her decision regarding my request. I understand each question I answered on the questionnaire. I responded to truthfully, accurately and completely. Before receiving a consultation with the Consulting Licensed Physician, I will ensure that I have completed the following: Accurately and honestly completed a comprehensive physical examination by an Licensed physician or Nurse Practitioner and completed the labwork required by the consulting licensed physician. I also understand that there may be additional out of pocket expense for my comprehensive physical examination and/or additional laboratory services that may be required by the consulting licensed physician.
*

I have read and agree to the above
I am soliciting this site to determine whether or not I fit the criteria for certain prescription medications and nutrients. I am not currently seeing my regular primary care physician at this time because: A) this site is more convenient. b) for other personal reasons.
*

I have read and agree to the above
In accordance with the United States Arbitration Act, I agree that any dispute arising out of or related to, the provision of services by the "Consulting Licensed Physician", by HRT Centers of America LLC, its affiliates, or their employees, partners and agents, shall be subject to final and binding arbitration exclusively through the procedures of the American Arbitration Association
*

I have read and agree to the above
Refund Policy

All sales are final on all products and services once they are paid for. No refunds will be issued, only damaged products will be replaced once damaged products are mailed back to HRT Centers of America LLC's mailing address.
*

I have read and agree to the Refund Policy
Consultation Cancellation/Re-Scheduling Policy

A 48-Hour notice is needed for all consultations that need to be re-scheduled; otherwise you will be required to pay $100 to the Consulting Licensed Physician's office before rescheduling your consultation. Lastly, it is mandatory to be on time for your exact reserved consultation appointment time; otherwise if you are more than 5 minutes late, you will be charged the $100 rescheduling fee everytime you are late or a no-show. No services will be provided by the consulting licensed physician until you receive your consultation; even if you received the comprehensive physical examination and/or labwork.
*

I have read and agree to the Cancellation/Re-Scheduling Policy
Privacy Policy

At HRT Centers of America LLC, we have taken the necessary security measures to ensure that all your information is protected against loss, misuse or alteration of data. Your information is only viewed by our highly qualified and trained staff and our consulting physician's office. Your personal contact information, including but not limited to your email, phone numbers and address are never sold or rented. We only use your contact information to coordinate your services at HRT Centers of America LLC and to keep you updated on current news and specials. At any time you may opt out of receiving mailings, emails or phone calls from us by sending us an email at support@HRTCentersOfAmerica.com with your full name and birthdate stating that you would like to "cease receiving" correspondences at this time from HRT Centers of America.
*

I have read and agree to the Privacy Policy
Driver's License Picture (For Security and Verification Purposes): *
Signature (Type Full Name) *
Signature (please sign with mouse or finger on a touchscreen)*

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- Month - Day Year
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General Information: Part 1

Goals: Part 2

Medical History/Lifestyle: Part 3

Males ONLY

Females ONLY

Comprehensive Laboratory Tests Ordering: Part 4

Liability Waiver: Part 5