Male Wellness Intake Form -

Wellness Program Intake

Men’s Wellness Program Intake

For men interested in our Foundation, Optimization, or Elite wellness programs. This intake gives Dr. Thomas the information she needs to recommend the right tier and design a safe, personalized protocol.

🔒 Submissions are sent directly to Dr. Thomas’s clinical team via secure email. An initial consultation and lab work are required before any prescription can be issued.

Identity and Contact

Full name

Date of birth

Mobile phone

Age

Existing Sure Success Wellness patient?

Tier of Interest

Dr. Thomas may recommend a different tier based on your goals and history. Selecting one helps us start the conversation in the right place.

Foundation — $1,995 (3-month) Optimization — $4,495 (6-month) Elite — $8,995 (12-month) Not sure — please recommend

Treatment Preference

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Enclomiphene is available with any tier as an alternative or complement to traditional TRT. Unlike testosterone replacement, Enclomiphene stimulates your body’s own testosterone production by working at the pituitary — preserving fertility and natural testicular function. Dr. Thomas will confirm the right approach for your goals, labs, and life stage at your consultation.

Which treatment approach interests you most? You can change your mind at your consultation.

Standard TRT (injection or cream) Enclomiphene (preserves fertility and natural production) Combination approach (TRT plus supportive meds) Not sure — please recommend

Anything specific you want Dr. Thomas to know about your treatment preference?

Your Goals

Describe your primary goal in your own words

Current Symptoms (past 30 days)

ADAM Screen (Low Testosterone Quick Check)

The Androgen Deficiency in Aging Males (ADAM) screen. Check anything that applies to you:

Medical History

Please check anything that applies to you:

Other significant medical conditions or surgeries

Fertility and Family Planning

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Standard TRT can affect fertility. Gonadorelin and Enclomiphene options can preserve it. Dr. Thomas will discuss options based on your plans.

Family planning status:

No future children planned May want children in the future Actively trying to conceive Not applicable or uncertain

Past Hormone Therapy

Have you used testosterone therapy or related medications before?

Never Currently using Used in past

If yes — type, dose, duration, and reason for stopping (if applicable)

Have you used any of the following?

Current Medications and Supplements

Prescription medications (name and dose)

OTC medications and supplements

Drug allergies and reactions

Lifestyle Baseline

Avg sleep hours per night

Exercise days per week

Stress level (1-10)

Current weight (lbs)

Height

Alcohol drinks per week

Tobacco use

Type of exercise

Recent Lab Work

Have you had recent (within 6 months) lab work — especially testosterone, PSA, or CBC?

Yes — I can share results Yes — do not have on hand No — would like labs ordered

If yes, which labs and any abnormal results you remember

Consent and Acknowledgment

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Please read carefully: TRT and related medications (Anastrazole, Gonadorelin, Enclomiphene) require ongoing medical supervision with regular bloodwork to monitor testosterone, estradiol, hematocrit, PSA, and cardiovascular safety. Dr. Thomas will only prescribe what is appropriate for your individual case after an initial consultation and baseline labs.

Signature

Signature (type your full legal name)

Today’s date

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Intake Form Submitted

Your email client should have opened with your responses ready to send to Dr. Thomas’s team.

If nothing happened, please email your form directly to [email protected] or call us at (317) 253-7795.

A member of our team will reach out within one business day to schedule your consultation.