Male Wellness Intake Form -

Full Name

First

Last

Date of Birth

Email Address

Phone Number

Make sure this a mobile phone to receive text messages

Address

Address Line 1

Address Line 2

City

State

Zip Code

Marital Status

Sex at birth

Genetic Background

Tier of Interest

Your Goals (click all the apply)

Describe your goals in your own words

Past Hormone Use

Never
Used in the past
Currently using

Hormones that you currently take or taken in the past?

Any Hormones that your currently take not list above

e.g. steroids

Current Symptoms (past 30 days)

Severity of symptoms

Selected Value: 0

0 is mild, 5 is moderate, 10 is severe

Adam Screen (low testosterone quick check)

Treatment Preference

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

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.

Fertility and Family Planning

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

Do you have any of the followin?

Past of Current Medical History

List any medical problems not listed above

Past Surgical History

List Current medications, supplements and over the counter medicines

Please enter one medication/supplement per line.

Please list any food or medicine allergies

Does anyone in your family have any Medical problems?

Review of Symptoms: General

cold hands and feet
fever
fatigue
daytime sleepiness

Review of Symptoms: Head, Ears, Eyes:

ROS: Musculoskeletal

ROS: Mood/Nerves

ROS: Cardiovascular

ROS: Urinary

ROS: Digestion

ROS: Respiratory

ROS; Skin

Date of most recent Prostate exam?

Last PSA level

Average sleep hours per night

Do you have problem staying asleep or getting to sleep?

Exercise days per week

Type of exercises

e.g. weights, walking

Do you follow any special diets?

How many meals do you eat a day?

How many meals do you eat out per week?

Stress level (1-10)

Current weight (lbs)

Height (feet, inches)

Alcohol drinks per week

Tobacco use or Vaping History

Have you taken any recreational drugs in the past?

Any Recent Lab Work?

Yes – I can share with you
Yes – do not have to hand
No – would like labs ordered

Emergency Contact Name

Emergency Contact Phone Number

Primary Care Doctor Name

Our office provides natural medicine and weight loss services to our patients. We do not offer primary care services. We require all patients to establish themselves with a primary care physician and provide our office with this information. We can send out referrals related to your care at our office. We may ask that your primary care doctor request referrals if needed. Our staff does not have hospital privileges and we are unable to treat patients at any hospital. We do not have a practitioner on call for emergencies. If you develop or experience an emergency medical situation, you are advised to contact 911.

PCP phone number

Tier Prices

Thank you for selecting Dr. Sheila Thomas for your health care needs. We are honored to be of service to you and your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all services will be due at the time services are rendered, unless prior arrangements have been made. NO CHECKS. I agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection FEES, attorney’s FEES and court FEES. I have read and understand all of the above and have agreed to these statements.

All Statements on this patient intake form are accurate and true to the best of my knowledge. I understand that treatments will be based on the information provided herein. If I willingly withhold knowledge from my treating physician, I accept full liability from any consequences arising there from.

Consent and Acknowledgment

I understand TRT and related therapies require a clinical evaluation and ongoing safety monitoring.
I acknowledge that standard TRT can affect fertility and I will discuss preservation options if relevant.
I confirm that the information above is accurate to the best of my knowledge.

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 (type your full legal name)

Past Current symptoms

Date