* Required fields
Name *
E-mail Address *
Street Address:
City and State:
Zip Code:
Phone Number: *
Fax Number:
What is the best way to get in touch with you? *
Source: How did you find out about us? *
Occupation *
Height: *
Weight: *
Age: *
Injuries - Past and present. Please list all: *
I have a history of thyroid disease. *
NO
YES
I was treated for hypothyroidism in the past. *
NO
YES
I have all/part of my thyroid removed. *
NO
YES
I have hypothermia/low body temperature. (I feel cold when others feel hot. I need extra sweaters,etc.) *
NO
YES
I have/had cancer. *
NO
YES
I have diabetes. *
NO
YES
I have heart disease. *
NO
YES
I have regular exposure to chemicals/toxins. *
NO
YES
I have regular exposure to excessive stress. *
NO
YES
I use Human Growth Hormone. *
NO
YES
I use Testosterone. *
NO
YES
I use Estrogen. *
NO
YES
I use thyroid medication. *
NO
YES
I use Progesterone. *
NO
YES
I use DHEA. *
NO
YES
If you use any of the hormones above, please list type, dosage and frequency of therapy.
Have you recently lost or gained weight? *
When did this weight change take place? *
If so, how much have you lost or gained?
How much has your pant or dress size changed? *
Why did this change happen? Did you try something new? Exercise or nutrition wise? *
What is your current body fat %? *
What is your current dress or pant size? *
What method was used for measuring your body fat %?
3-Site
4-Site
6-Site
9-Site
Pectoral -
Sub scapula -
Triceps -
Supra iliac -
Abdomen -
Thigh -
Calf -
Bicep -
Digital photos of the front, back and side are recommended. A swimsuit is ideal but, shorts and tank will work. Will you be including photo's with this completed form?
NO
YES
What is your goal for the next three months? *
Gain muscle/lose fat - *
Gain weight - *
Lose as much fat as possible - *
Competition/Pageant/Event (Reunion, wedding, etc) - *
Please explain: Other -
Number of meals eaten per day. Please include snacks, as well: *
0
1
2
3
4
5
6
7
8
9
10
Which best describes your eating habits? *
Poor
Average
Excellent
Are you currently following any popular diets or nutrition plans? *
No
Atkins
The Zone
South Beach
Other
Are you currently participating in a weight loss program? *
No
Jenny Craig
Weight Watchers
Nutri-Slim
Other
I drink beer/wine (# of drinks daily): *
0
1
2
3
4
5
6
7
8
9
10
I drink hard liquor (# of drinks daily): *
0
1
2
3
4
5
6
7
8
9
10
I drink coffee (# of drinks daily): *
0
1
2
3
4
5
6
7
8
9
10
I drink soda/pop (# of drinks daily): *
0
1
2
3
4
5
6
7
8
9
10
Please list any supplements you are currently taking:
Do you have any food allergies?
What is your favourite food?
How many times per day can you realistically eat? *
What food would you NEVER eat?
What food do you currently eat, that you are not willing to give up?
Write down the foods and portion sizes of everything you ate YESTERDAY: (meals 1 to 6) *
Write down the foods and portion sizes of everything you eat TODAY: (meals 1 to 6) *
Wlease write down the foods and portion sizes of everything and record TOMORROW: (meals 1 to 6) *
Will you be working out at a commercial health club? *
NO
YES
If YES, what equipment do they have? If they have a website, send it to me as they often list their equipment online:
If NO, where will you be exercising and what will you have access to?
Will you be working with a personal trainer? *
NO
YES
Not Sure
I accept, understand and agree to the following: I am freely seeking medical consultation via the Internet. I am aware that the physician reviewing my medical history will not have the opportunity to conduct a personalized in-person physical examination. I am soliciting this site because I am seeking a specific prescription medication to treat an already-identified medical or cosmetic condition. I understand that my "Medical History" will be reviewed by a physician who is licensed in the U.S. *
Yes
No
I acknowledge and agree that I, under no undue duress, initiated contact with YOUTH-Rx. I am aware that my prescribing physician may be located in another state or country other than my own and that said physician may NOT be licensed to practice medicine in my state of residence (referred to as the "Consulting Physician"). *
Yes
No
I agree that all on-line medical consultations, diagnoses and treatments will be deemed to have occurred in the state where the physician is "Physically" located and/or licensed to practice medicine. *
Yes
No
I am under the care of a primary care physician and I do not consider the "Consulting Physician" to be my primary care physician (unless I visit the said physician for an in-person personal doctor/patient consultation). I will not rely on or substitute the advice given by the "Consulting Physician" should it contradict the advice given to me by my primary care physician. *
Yes
No
I will not make a claim that the "Consulting Physician" acted unprofessionally or below the standard of care solely because the physician did not personally perform a physical examination on me. *
Yes
No
The "Consulting Physician" reviewing my "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. *
Yes
No
I also understand that failure on my part to provide truthful, accurate and complete information to the "Consulting Physician" could cause him or her to unknowingly make an inappropriate treatment decision affecting my physical or mental health. To prevent this occurrence, I acknowledge that it is of utmost importantance that I am truthful when answering the questions asked in the "Medical History". *
Yes
No
Before taking any medication prescribed, I will ensure that I have completed the following: Accurately and honestly completed a comprehensive physical examination by my primary care physician. I received a copy of the written report of said examination and that I have identified my responses to the "Medical History" any findings from my physicial examination that are not within the accepted average range. *
Yes
No
I understand YOUTH-Rx does not practice medicine. I understand that YOUTH-Rx is a management service organization that received my request for a physician consultation and, in turn, directs that request to a qualified independent physician for review and response.The physician who reviews my medical history and who makes the medical determination as to whether or not I receive the medication I am seeking is solely an independent contractor of YOUTH-Rx and is not an agent or employee of YOUTH-Rx. *
Yes
No
I understand YOUTH-Rx does not direct,control or influence the treatment decisions made by the Consulting Physician with respect to my care and/or my request from YOUTH-Rx is not liable for any negligent act or omission of the Consulting Phsician.I understand that my medical records become property of the Consulting Physician or YOUTH-Rx and that in addition,YOUTH-Rx will have continuing access, the right to copy and retain any and/or all portions of my medical record. I am over 18 yrs of age. *
Yes
No
I am soliciting this site to determine whether or not I fit the criteria for certain prescription medications. 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. *
Yes
No
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 Physician", by YOUTH-Rx, 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. *
Yes
No
I understand that this agreement is voluntary and that it is binding to any individual or entity claiming by or through me or on my behalf; and I chose this site on my own accord from several Internet options; I hereby release YOUTH-Rx and the "Consulting Physician" from all claims that the "Consulting Physician" acted unprofessionally or below the standard of care solely because he/she did not perform a physical examination on me. *
Yes
No
I understand that this release includes, but is not limited to, my agreeing to the following: I have truthfully answered all of the questions and have provided complete and accurate answers to the questions. I further agree to make the YOUTH-Rx physicians aware of any changes in my medical condition in the event I revisit this site to obtain more or different medications. *
Yes
No
I am aware of potential side effects associated with this medication. I personally accept all risks involved in taking medication and will not seek any indemnification, any damages of any kind or, any other liability from YOUTH-Rx, its parent, subsidiaries, affiliates, contractors or partners. If I experience any of the side effects; I understand that no doctor, nurse or administrative personnel can guarantee that the prescription medicines I am requesting will provide the results I seek. *
Yes
No
I understand it is my responsibility to have an annual physical examination, including any suggested laboratory tests, to ensure that I do not have a condition which will make my taking this medicine inappropriate or dangerous. I have consulted with my physician and/or pharmacist and am not currently taking any medications or combination of medications that will make the medication I am requesting inadvisable to take (contraindicated). *
Yes
No
I will notify my primary care physician that I am taking the medication that I requested so that he/she may advise me as to whether or not I should continue or discontinue its use. This document also serves as my informed consent to allow YOUTH-Rx access to any of my medical information, including all medical data contained in the "Medical History" including, but not limited to, any health information, regarding HIV, mental health, alcohol, drug or substance abuse conditions or treatments. *
Yes
No
I hereby authorize my physician to release or disclose to YOUTH-Rx any and all medical information. I accept that, with the exception for action formerly taken with the regard to this authorization, I can void this authorization at any time by providing notices to YOUTH-Rx or, to the "Consulting Physician". This consent does not give YOUTH-Rx, its parent or sister companies, the right to sell my name or information to any third party. *
Yes
No
In consideration of YOUTH-Rx undertaking to render the undersigned patient any administrative or any other services relating in any way to this agreement or, YOUTH-Rx disclosing information or methods of treatment to patient (either of which are deemed sufficient consideration for this agreement). *
Yes
No
I understand that in the event any court determines that the undersigned patient sought medical treatment or medical prescriptions through YOUTH-Rx for the possible apparent purpose,directly or indirectly,of deception,assisting any investigation or rendering of any type of assistance to,or disclosing of any information pertaining to YOUTH-Rx its procedures,officers,directors,or medical protocols,to any news organization,possible or actual competitor,any type of government agency,any investigator *
Yes
No
I understand I will not give any information to any party for possible or apparent purposes of securing any information, confidential or otherwise, about YOUTH-Rx, its officers, directors, shareholders, affiliates, banking relationships, contractors, medical laboratories, contracting physicians, medical protocols, sources of pharmaceuticals, proprietary medical treatment protocols or YOUTH-Rx system of pharmaceuticals procurement and dispensing. *
Yes
No
The undersigned patient knowingly, expressly and irrevocably consents to a judgement in favor of YOUTH-Rx, its officers or any party proceeding under the authority of its instrument, of liquidated damages, jointly and severely against the undersigned patient, as well as any express or apparent principle (including a patients employer) as an authorized or apparent agent of his/her principle or employer, in the amount of Three Million Dollars ($3,000,000). *
Yes
No
The above liquidated damage amount is hereby accepted by the undersigned as a reasonable amount for engaging in such acts of deception and because they are difficult to ascertain. The undersigned patient engaged in such deception or any of the above described acts agrees on behalf of himself and his/her principle, to pay reasonable attorney's fees and costs incurred by any person or entity seeking to enforce this agreement. *
Yes
No
I understand this agreement represents the complete and entire agreement between the parties to it. I understand that prescription medications purchased cannot be refunded. *
Yes
No
I understand all information, items and services contained on this website are provided "as is" without warranty of any kind, expressed or implied. In using this website, I understand and agree: (A) that YOUTH-Rx is not responsible for the negligent or intentional acts or omissions of any health care provider or supplier that may be linked with or for any action or inaction taken by me in reliance upon the information communicated to me via this website. *
Yes
No
In using this website, I understand and agree: (B) that the total liability of YOUTH-Rx and its affiliates, if any, arising from or related to interactions I have with or, through this website (whether the claim is contract, tort, warranty, negligence, malpractice, fraud or otherwise) is limited to the purchase price of any products in any relevant transaction and (C) that YOUTH-Rx shall not be liable for any direct, indirect, special, incidental, consequential or punitive damages. *
Yes
No
In accordance with the above understanding, I agree to release YOUTH-Rx, their employees, agents, corporate affiliates and related parties from any and all liability associated with or arising from the physician consultation or from the medical, physical, behavioral or other effects of any medication that may be ordered, prescribed or purchased, as a result of the physician consultation. *
Yes
No
If any provisions of this above agreement is held to be void, unenforceable or illegal, then I agree that the agreement will be changed or limited only to the extent necessary to enable the remaining provisions to be of full force and effect. *
Yes
No
Signature: *
Date: Month/Day/Year: *
