* 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 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
The "Illinois Licensed 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 "Illinois Licensed 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 an Illinois Licensed 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 IL.Licensed physician for review & reply.The IL.Lic physician who reviews my medical history & 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 IL.LicensedConsulting 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 Physician.I understand that my medical records become property of the IL.Consulting Physician and that in addition,YOUTH-Rx may 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 "Illinois Licensed 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 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 Illinois Licensed 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 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
Signature: *
Date: Month/Day/Year: *
