Client Intake/ Lifestyle Form

* Required fields
Name *
E-mail Address *
Drivers License Number *
Phone Number: *
Address Line 1: *
Address Line 2:
City: *
State: *
Zip Code: *
Height: *
Weight: *
Age: *
Gender *	Male Female
Body Frame: *
Month of Birth: *
Day of Birth: *
Year of Birth: *
Marital Status: *
Number of Children: *
Occupation: *
Primary Care Physician: *
Address Line 1:
Address Line 2:
City: *
State: *
Zip Code: *
Referral Source: How did you find out about us? *
Consultant
YOUTH-RX Location *
Do you suffer from mood swings? *
Are you depressed often? *
Do you often feel anxious or stressed out? *
Do you keep in touch with friends? *
Is your sex life declining? *
Do you have trouble falling or staying asleep? *
Is your cholesterol over 200? *
Is your blood pressure high? *
Does the skin on your face, neck, upper arms and abdomen appear to hang or sag? *
Do you think you look older than people your age? *
Do you have cellulite on your thighs? *
Are you in poor physical shape? *
Is it difficult for you to lose weight? *
Have you developed a spare tire or love handles? *
Does your musculature look youthful? *
Does it take longer for cuts and bruises to heal or for wounds to close? *
Is it getting harder to exercise? *
Is your endurance less? *
I have to struggle to finish jobs. *
I feel a need to sleep during the day. *
I feel isolated even when I am with other people. *
I have to read things several times before they sink in. *
It is difficult for me to make friends. *
I have difficulty controlling my emotions. *
I often lose track of what I want to say. *
I lack confidence. *
I feel as if I am a burden to people. *
I feel worn out even when I've done nothing. *
I often forget what people have said to me. *
I am easily irritated by other people. *
I have erectile dysfunction. *
I have hot flashes. *
I have decreased strength. *
I have decreased muscle mass. *
I have bone loss. *
Do you feel happy most of the time? *
	Hypothyroid Symptoms:
I have a family history of thyroid disease. *
I was treated for hypothyroidism in the past. *
I have had all/part of my thyroid removed. *
I have hypothermia/low body temperature (I feel cold when others feel hot. I need extra sweaters, etc). *
My hair is coarse, dry, brittle, breaking and falling out. *
My skin is coarse, dry and scaly. *
I have puffiness and swelling around my eyes and face. *
I have developed carpal-tunnel syndrome or, it is getting worse. *
I am having trouble conceiving a baby. *
	Medical History:
Date of Last Physical: *
I have frequent headaches. *
I have/had cancer. *
I have diabetes. *
I have heart disease. *
I have arthritis. *
I have liver disease (hepatitis, cirrhosis). *
I have mind problems (depression, anxiety, panic attacks, schizophrenia). *
I have HIV / AIDS. *
Please list any surgical procedures, including plastic surgery:
	Medication/Drug Consumption:
I use antibiotics/anti-fungals. *
I use antidepressants. *
I use insulin injections. *
I use Aspirin. *
I use heart medication. *
I use high blood pressure medication. *
I use sleeping pills. *
I use diuretics (water pills). *
I use ulcer medication. *
I use recreational drugs. *
Please list the name, dosage and frequency of all medications you are taking:
	Lifestyle:
I drink beer/wine (# of drinks daily). *
I drink hard liquor (# of drinks daily). *
I drink coffee (# of drinks daily). *
I drink soda/pop (# of drinks daily). *
I use chewing tobacco (# of times daily). *
I smoke cigarettes (# smoked daily). *
I smoke cigars (# smoked daily). *
I have regular exposure to chemicals/toxins. *
I have regular exposure to excessive stress. *
	Supplement Usage:
I use protein supplements: *
I take a multi-vitamin with minerals. *
I take saw palmetto. *
I take silymarin/milk thistle. *
Please list any other supplements you are taking:
	Hormone Usage:
I use Human Growth Hormone. *
I use Testosterone. *
I use Anti-Estrogen. *
I use thyroid medication. *
I use DHEA. *
If you use any of the hormones above, please list type, dosage and frequency of therapy:
	Liability Waiver:
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, a Illinois Licensed physician will 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 understand YOUTH-Rx does not direct,control or influence the treatment decisions made by the Consulting Illinois Licensed 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 IL licensed Phsician.I understand that my medical records become sole property of the Consulting Illinois Licensed Physician and copies may be made available to YOUTH-Rx
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. *
The IL. Licensed 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. *
Before taking any medication prescribed, I will ensure that I have completed the following: Accurately and honestly completed a comprehensive physical examination by an IL. 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. *
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 IL. Licensed 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. *
Signature: *
Date: Month/Day/Year: *
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I have read and agree to the Privacy Policy *

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