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:__________
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:_______
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
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.
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.

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

privacy 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