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Bio Hacking Luxe – Hormone Replacement Therapy Intake Form
(Confidential & HIPAA-Protected Health Information). Please complete before your appointment.
Patient Information
First Name
*
Last Name
Phone Number
*
Date of Birth
Email
Age
*
Sex
*
Address:
*
Emergency Contact
Please provide a next of kin's contact to contact incase of any emergencies. Make sure the contact is active.
First Name
Last Name
*
*
Email Address
Phone Number
*
Medical History (check all that apply)
Medical History (check all that apply)
Cardiovascular disease
Diabetes
Kidney disease
Liver disease
Autoimmune disorders
Thyroid conditions
Cancer (current or past)
History of blood clots
Neurological conditions
Psychiatric conditions
Respiratory conditions
Current or recent infections
Other:
Surgical & Hospitalization History
*
Current Medications & Supplements
*
Allergies
*
Allergies
No known allergies
Muscle growth / performance
Recovery from injury/surgery
Anti-aging / longevity
Sexual wellness / libido
Energy / vitality
Cognitive support
Mood support
Other
If yes, list allergies:
For Female Patients Only
Pregnant?
*
Pregnant?
A
Yes
B
No
Breastfeeding?
*
Breastfeeding?
A
Yes
B
No
Menstrual cycle (regular/irregular/absent):
*
Birth control or hormone therapy type:
*
