Our mission is to provide the highest quality treatments, products and testing to promote

                   optimal health, beauty and longevity in a non-pharmaceutical environment
               Researched by The  Anti-Aging Clinic   "Aging Younger ®"            
 

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Anti-Aging Clinic Profile Sheet
For MALE-BHRT, Bioidentical Hormone Replacement Therapy-

 Please take the time to fill out this form for
our records. The information will be treated with
confidentiality. If you need additional information or have
any questions or comments, please call: 954-742-4430

Personal Information

Date _________/____/_______

Last name:________________
First name: _____________ Middle initial ______

Date of birth:___/__/____  Sex:Male  __ / Female __               
Height ___________  Weight   _________

Marital status, circle one:    Single     Married       
Divorced    Widow

Address: ___________________________________  

City: ____________ State: ______ Zip code________

Home phone number: (____) __________
Cell Phone number: (____) ___________

Email address: ______________@ ___________

Name, phone and relationship to call in case of
emergency: _____________________________

Your Occupation:_________________________

How were you referred? __________________

                                                                      CLIENT CONSENT

I understand that balancing the endocrine (HORMONAL)
system is an essential element in achieving a better
state of health. This goal can only be achieved through
a professional triage consisting of a hormone specialist,
or medical doctor who has received training in
Bioidentical Hormone Replacement Therapy. I
understand that the Anti-Aging Clinic Assoc., Inc., and
it’s associates, collect data from me from a
questionnaire that was provided to them by the
experts in this field and that those experts will
receive and review this data and will receive and
review my results of a saliva test.  I understand that
I must follow the directions contained therein and
collect for myself at home these samples and these
same experts will assess disease states and will not
diagnose diseases or prescribe medications. In
accomplishing this, these experts may us
unconventional approaches to disease management
that some healthcare practitioners may not agree with.

I understand that hormonal balance is our goal and
will take time and cooperation between willing qualified
practitioners and myself.  There might be a need to
adjust strengths of medications used, dosage forms or
change in treatment, which can take 4 to 6 months or
longer if necessary. I have read this client consent
form and sign my agreement of my own free will:

PRINT NAME HERE__________SIGN HERE_______________

DATE:__________

Medical Information

1. Are you currently under the care of a
   physician? __YES     __NO If yes, you may need his/her
  consent to balance hormones.

2.  Do you use Soy or Tofu? __YES       __NO

3. Are you taking any medications, vitamins or
  herbal remedies?  __YES        __NO

4. If yes, what do you take? ______________________

5. For what condition (s) are you taking it/them? ____

____________________________________________

6. Have you ever been hospitalized? __YES__NO

If yes please explain: __________________________

7. Are you currently taking hormones? __Yes  __NO
If so what is your regimen? ____________________

SLEEP

1. Average hours per night _____
   Daytime naps __YES__NO
    Insomnia? __Yes __NO

2. Do you dream? __Yes __No  / How do you dream
    pick one? ___Good Dreams  ___Bad Dreams 

3. Do you have problems sleeping?  __Yes __No

4. Do you wake up in the morning feeling awake and
    refreshed?  __Yes    __No

5. Do you smoke ? __Yes  __No      If you smoke,
     cigarettes per day: ______________________

6. Do you drink alcohol:__Yes __No--If yes  ____Liquor   
_____Beer   ____Wine  /  Drinks per day: ____
Drinks per week:_______

Specific Health Questions

Have you ever been treated for, diagnosed as having, or are
you currently suffering from any of the following conditions:

1. Cancer, malignant tumors?__ YES __ NO

2. HIV positive or AIDS?__ YES__ NO

3. Acute allergic reactions?__ YES__ NO

4. Acute infections?__ YES  __ NO

5. Acute inflammation?__ YES __ NO

6. Chronic inflammation?__ YES__ NO

7. Hepatitis or liver disease?__ YES __ NO

8. Heart disease?__ YES  __ NO

9. Hypertension?___ YES __ NO

10. Respiratory disease?__ YES__ NO

11. Kidney failure?  ___ YES __ NO

12. Thyroid function disorders?__ YES__ NO

13. Vascular disease, venous inflammation,
       deep vein thrombosis or unexplained calf pain  :                                                  
   __ YES__ NO

14. Skin disorder, inflammation, eruption or
        infection?__ YES __ NO

15. Diabetes?__ YES__ NO

16. Intestinal or digestive conditions?__ YES__ NO

17. Abdominal or inguinal hernias?__ YES__NO

18. Mental and emotional disorders? __ YES__ NO

19. Do you have sensitive skin or bruise easily?
       __ YES    __ NO    

20. Are you sensitive to cold temperature?
          __ YES__ NO

21. Do you suffer from constipation?__ YES__ NO

22. Are you taking laxatives?___ YES__ NO   

23 Are you taking diuretics?__ YES__ NO

24. Any significant weight fluctuation in the last
        10 year?__ YES __ NO

If you answered "Yes" to any of these questions,
please explain

Question #             Explanation:                                 

__________            ____________________________________________________

__________            ____________________________________________________

__________            ____________________________________________________

__________            ____________________________________________________

__________            ____________________________________________________

__________            ____________________________________________________

__________            ____________________________________________________

__________            ____________________________________________________

__________            ____________________________________________________

__________            ____________________________________________________

__________            ____________________________________________________

__________            ____________________________________________________

__________            ____________________________________________________

__________            ____________________________________________________

Reason for Visit, Motivations and Expectations

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Authorization to take photographs

The undersigned hereby authorizes and consents to the
usage of photographs taken of their body before, during
and after any treatment, taken by Anti-Aging Clinic
personnel, for teaching, marketing, science journals and
other viewing purposes.  Yes /  No

Yes I do_______________________________________         __________________

No I do not_____________________________________           _________________

                        Clients signature                                                                                                                 Date

Males only:

Instructions: Circle the number which best describes the
intensity of your symptoms. If you do not know the answer
to the question leave it blank. 0 means that the symptom is
not present----then 1 =Mild ----then 2= Moderate ----then
3=Severe

Section A:

1. A feeling of bladder fullness:-- 0---1--2---3

2. Difficulty urinating--0---1--2---3

3. Increased straining with smaller and smaller amounts of
    urine: 0---1--2---3

4. Pain or burning while urinating-0---1--2---3

5. Wake up at night to urinate -0---1--2---3

6. Dripping after urination -0---1--2---3

7. Rose Colored (bloody) urine-- 0---1--2---3

8. Pain or fatigue in the legs or back-- 0---1--2---3

9. Lack of sex drive -- 0---1--2---3

10. Ejaculation causes pain-- 0---1--2---3

11. Past or present rash on penis-- 0---1--2---3

12. Cloudy urine-- 0---1--2---3

13. Strong smelling urine-- 0---1--2---3

14. Back pain in the kidney areas-- 0---1--2---3

15. History of kidney or bladder infections-- 0---1--2---3

16. Have used antibiotics to control urinary tract
       infections: Yes or No

Date last used____________ Treatment duration______

Section B

1. Difficulty attaining and/or maintaining an
    erection-- 0---1--2---3

2. Low sex drive-- 0---1--2---3

3. Premature ejaculation-- 0---1--2---3

4. Pain or coldness in genital area-- 0---1--2---3

5. Can’t hold urine-- 0---1--2---3

6. General water retention-- 0---1--2---3

7. Varicose veins on scrotum-- 0---1--2---3

8. Low sperm count-- 0---1--2---3

9. Infertile-- 0---1--2---3

Section C:

1. Discharge from penis-- 0---1--2---3

2. Swollen genitals-- 0---1--2---3

3. Swelling in groin-- 0---1--2---3

4. Frequent urination-- 0---1--2---3

5. Rarely need to urinate-- 0---1--2---3

6. Difficulty passing urine-- 0---1--2---3

7. Dripping after urination-- 0---1--2---3

8. Have venereal disease (gonorrhea, syphilis, herpes
     or other) now (Yes No)

  What demands are you making
  on your body?

   Answer "Yes" or "No" to each of these questions.

  YES     NO

1. Are you being treated for any disease or serious
    condition?

 

 

2. Is your work a source of stress for you?

 

 

3. Do you Skip meals or follow a popular diet plan?

 

 

4. Do you feel overscheduled and rushed?

 

 

5. Are you taking more than one prescription
     medication?

 

 

6. Do you experience a lot of conflict or stress in your
     life ?

 

 

7. Do you have caffeine or soft drinks more than once
    a day?

 

 

8. Have you experienced a major trauma or loss in the
    last 5 years?

 

 

   What kind of support are you giving
   your body?

                                          Answer these "Yes" or "No".

      YES    NO

1. Do you eat protein at every meal?

 

 

2. Do you eat 4 or more servings of fruit & vegetables
    a day?

 

 

3. Do you minimize simple carbohydrates, alcohol and
    sweets?

 

 

4. Do you exercise 4 or more times a week?

 

 

5. Do you feel you make adequate time for your
     needs?

 

 

6. Do you take high-quality nutritional supplements?

 

 

7. Do you try to minimize toxins and processed foods
     in your diet?

 

 

  1. What is your age?  ____________________ 

Click here Hormone pathway

 

Client consent for treatment

Every client must read and sign the authorization and release form in conjunction with this Questionnaire. Authorization and release form, which is located at highlighted link provided.
Click hereAuthorization and release form

Every client must read and sign our privacy policy located at the highlighted link below:

Click hereprivacy policy

Being aware of the preceding, I hereby knowingly and voluntarily consent to all of the above-described treatments provided by the Anti-Aging Clinic Assoc., Inc.

and acknowledge the suggestions of treatments and products described to me to may satisfaction.

_________________________________________________            _______________________
Client signature                                                                                        Date

_________________________________________________            _______________________
Witness signature                                                                                    Date

A NOTARY IS REQUIRED FOR WITNESS WHEN SIGNING OUTSIDE THE CLINIC.

Print this questionnaire, complete and sign it; then print the Authorization and Privacy Policy read and sign and date both of them; then place all in an envelope and mail to the below address.
 

We will call you for follow up and credit card information.

   Anti-Aging Clinic Assoc.
7134 West McNab Road
Tamarac, Florida 33321

Phone: 954-742-4430

All pages of this website are under copyright protection and may not be reproduced in any manner. You may print the page to answer questions and print the privacy page to sign and print the page or your authorization; all pages must be signed and mailed to the Anti-Aging Clinic at address above

[[disclaimer] “These statements have not been evaluated by FDA.  Treatments or products are not intended to diagnose, treat, cure or prevent any disease.”