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Anti-Aging Clinic Profile Sheet For
BHRT, Bio
Identical 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 the technician at:
954-742-4430.
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, medical
doctor
and compounding pharmacist who have received training in Bioidentical Hormone
Replacement Therapy.
I understand that the Anti-Aging Clinic Assoc., Inc., and it’s
associates,
collect
data from me in form of 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
in the saliva test kit and
collect saliva samples for myself at home. These
experts will
use the questionnaire and
the results of the saliva testing In
order to
assess disease states; but 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 it 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
_____________________SIGN ___________________DATE:__________
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1. Are you currently under the care of
a physician? _____ YES ____ NO
2. Do you use Soy or Tofu? _____
YES ____ NO
3. Are you taking any medications?
_____ 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:
______________________________________________________
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7. Are you taking vitamins or herbal
supplements? _____ YES ____ NO
List all herbal supplements you
take__________________________________________
8. Are you currently taking hormones?
_______Yes _____NO
If yes; 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 ___No 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: Y/N
or ____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. Are you
pregnant? _____
YES ____ NO
4. Acute allergic
reactions? _____ YES ____ NO
5. Acute
infections? _____
YES ____ NO
6. Acute
inflammation? _____
YES ___ NO
7. Chronic
inflammation? _____
YES ____ NO
8. Hepatitis or liver disease?
_____ YES ____ NO
9. Heart
disease? _____
YES ____ NO
10. Hypertension?
_____
YES ___ NO
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11. Respiratory disease?
_____ YES ____ NO
12. Kidney failure?
_____
YES ____NO
13. Thyroid function
disorders? _____ YES ____ NO
14. Vascular disease, venous
inflammation deep vein thrombosis or
unexplained calf pain ___ YES __ NO
15. Skin disorder, inflammation,
eruption or infection? _____ YES ____NO
16.
Diabetes?
_____ YES ____ NO
17. Intestinal or digestive conditions?
_____ YES ___ NO
18. Abdominal or inguinal
hernias? _____ YES ____ NO
19. Mental and emotional
disorders? _____ YES ___ NO
20. Have you received any injections---
(collagen, fat, cortisone,
etc.) ?___ YES ___ NO
21. Have you recently started using
contraceptive pills
or changed
dosage? ____YES___ NO
22. Are you under hormonal
treatment? _____ YES ____ NO
23. Do you suffer from severe
pre=menstrual syndrome _____ YES ____ NO
24. Do you have a regular menstrual
cycle? _____ YES____ NO
25. Are you taking anti-depressant
medication? _____ YES____ NO
26. Do you have sensitive skin or
bruise easily? _____ YES____ NO
27. Are you sensitive to cold
temperature? _____ YES ___ NO
28. Do you suffer from
constipation? _____ YES ___ NO
29. Are you taking
laxatives? _____ YES ___
NO
30 Are you taking
diuretics? _____ YES
___NO
31. Any significant weight fluctuation
in the last 10 year? _____ YES ___ NO
32. Do you have cellulite? _____Yes
____No /
When did you start noticing the appearance of cellulite?
______________________
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33. Where do you have cellulite?
Hips-----Buttocks-----Thighs------Arms-----
If you answered "Yes"
to any of these questions, please explain |
Question # Explanation:
__________
________________________________________________________
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________________________________________________________
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_______________________________________________________
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________________________________________________________
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_______________________________________________________
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_______________________________________________________
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_______________________________________________________
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_______________________________________________________
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_______________________________________________________
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_______________________________________________________
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_______________________________________________________
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_______________________________________________________
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_______________________________________________________
__________
_______________________________________________________
______________________________________________________________________
______________________________________________________________________
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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 and identity withheld.
Yes / No
Yes I will
allow_____________________ date_____________
No I do no allow____________________
date_____________
Clients signature on
one and Date
MENSTRUAL HISTORY:
1. Do you still have your uterus?
Y / N -
When was it removed?_____
2, Do you still have ovaries?
Y / N -
When were they removed?___
3. Have you had any problems associated with
the
surgery or absence
of these organs? __Y / N__
4. How old were you when you had your first
period?___
5. Do you still have your period? ___Y /
N___
6. Or, were your cycles ____regular or
____irregular
as a teenager?
7. Your periods were:
______Light, _____
Medium or _____Heavy
8. Presence of Menstrual cramps? ___Y /
N____
9. Did you miss school or work because of
them? ____Y / N_____
10. Have you use contraceptives ?__Yes __No
If yes, how long a
period of time?_______
NOTE: The reason for this question is:
Birth control
pills tend to
compress the cycle peaks.
11. When was your last menstruation?
___________
12. Have you ever been pregnant? Y / N How
many
times?___How many children do you have?___
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13. Any miscarriages? Y / N --If yes
how many ?____
14. Were there any problems during your
pregnancies?
#1 Y / N #2 Y / N #3 Y / N #4 Y / N
#5 Y / N OR any
others?______________________________
What were the
problems concerning item # 14
________________________________________
15. Any post-partum depression? ___Y /
N___
16. Did your periods return to the same as
before, after your pregnancies? __Y/N__
17. After child #1 did they? ___After child
#2 did they? __
After child #3 did they? ___After
child #4 did they? __
18. Did you nurse? ____Yes ___No
19. When did your periods become irregular?
_______
20. Your age at Menopause? _______ Means when your last eggs dropped or, if you
are not sure about that; when did your period stop?_________
Estrogen Imbalance |
What type of symptoms do you
currently
experience throughout the
month? Put an "X" to the left of each
you
have had or experienced—leave
blank if not. |
___Breast tenderness |
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___Increased breast size |
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___Suppression of
lactation |
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Headaches
(where) Place "X" next to those
relevant below |
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___Right side or |
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What type of
symptoms do you
currently experience throughout the
month?
Put an "X" to
the left of each you have
had or
experienced—leave blank if not. |
|
___Front of head or |
___Nausea /
Vomiting |
___Left side-- or |
___Bloating / Fluid
retention |
___Both over
nose and eyes |
___Hot flashes |
Place "X" next to
selection below
indicating Uterine cramps
and Uterine problems |
___Night sweats |
___V-Bad cramps |
___Insomnia
|
___Mild cramps |
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___Not at all |
Place an "X" beside each that is
relevant
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___Tiredness /
Fatigue |
___Decreased
libido |
___Could you nap in
midday |
___Vaginal
dryness |
___Depression |
___Painful
intercourse |
___Irritability &
anxiety |
___ Thickening of
vaginal wall |
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Urinary Track
infection "X" |
___Nervousness |
___Urinary
incontinence |
___Crying easily |
___Dry eyes |
___Dizziness |
___Dry skin |
___Cyclic weight
gain |
___Early mid
cycle spotting |
___Weakness |
___Decrease
length of flow |
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___Irregular
heartbeat |
|
___Rapid
heartbeat |
|
___Palpitations |
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Check any symptom you’ve
experienced in the last 3
months and give it a
grade. If you didn’t experience the
symptom, Mark "0" in None. O equals
none: 1 to 3 Mild
that is somewhat uncomfortable; 4 to 8 Moderate
that is
Hot Flashes; and 9 to 10 Very Severe is Hot flashes and
sweating all night
long.
MENOPAUSE ASSESSMENT:
Questionnaire1111111111111111
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Mild
1/3 |
Moderate/
Severe
4/8 |
Very Severe 9/10 |
None
0 |
1. My menstrual
periods are
irregular
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2. I have hot
flashes or night
sweats
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3. I have insomnia
or disturbed
sleep |
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4. I feel very
tired
weary minded,
no desire for
effort. |
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Mild
1/3 |
Moderate/
Severe
4/8 |
Very Severe
9/10 |
None
0 |
5. I am irritable,
sad, and
apprehensive. |
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6. I feel that I’ve
gained weight
compared to last
year. |
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7. My interest in
sex
isn’t what it used
to be. |
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8. I crave sweets,
carbohydrates or
alcohol. |
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9. I suffer from
vaginal dryness. |
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10. I have chilling
sensations
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11. I have
sensations of
dizziness,
swimming in
head. |
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Mild
1/3 |
Moderate/
Severe
4/8 |
Very Severe
9/10 |
None
0 |
12. I am anxious or
have anxiety
attacks. |
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13. I have
headaches of
any kind. |
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14. I feel stiff or
pain
in my joints,
especially in the
morning. |
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15. I sometimes
feel over-
whelmed or just
not myself. |
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16. Sensations of
numbness &/or
tingling of the
skin |
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17. I Feel like
bugs
are crawling on
my skin. |
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18. I feel
miserable
and depressed. |
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Mild |
Moderate/
Severe |
Very Severe |
None |
19. Quick heart
beat, fluttering,
pounding,
racing. |
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20. I have vaginal
burning & itching. |
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21. Painful
urination
increased
frequency |
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22. Leaking when,
coughing,
laughing,
sneezing or
hard work |
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23.
Leaking when
walking,
running,
climbing steps,
or light work. |
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24. Leaking urine
regardless of
activity, even
lying position. |
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OSTEOPOROSIS ASSESSMENT:
Section A. Uncontrollable Risk Factors / Answer Yes or
leave blank
for No
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Are you diabetic? |
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Do you have a
family history of osteoporosis? |
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Are you Caucasian,
Northern European or Asian? |
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Section A.
Uncontrollable Risk Factors / Answer Yes or
leave blank for No |
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Do you have a fair
or light complexion? |
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Do you have a
small-thin frame? |
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Are you over 40
years of age? |
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Are you over 70
years of age/ |
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Have you had a full
hysterectomy or had both ovaries
removed? (and your not taking
replacement hormones) |
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Did you breast-feed
at least one child? |
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Do you have a dairy
allergy or are you lactose intolerant? |
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Have you not had
children? |
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Are you currently
in or beginning menopause? |
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Have you lost any
height? (2-points if ¼ inch, 4-points ½ or more) |
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Do you have low
back pain or curvature? |
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Have you had a
history of broken bones? |
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Do you get cramps
in the legs or feet? |
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Do you experience
bone pain? |
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Do you have brittle
or soft nails? |
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Do you have
premature graying of hair? |
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Do you have
periodontal disease? |
SECTION B. Controllable Risk Factors
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Is your diet
deficient in calcium? Yes___ No____
If No, circle what kind of calcium
? 1. Calcium carbonate.
2. Citrate. 3. Hydroxi-Appitide. 4. Coral Calcium |
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Is your diet
deficient in vitamin D? Yes__ No__
If No, how much do you take_____ |
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Do you smoke
cigarettes? |
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Do you drink
alcoholic beverages? |
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Do you avoid milk
or other dairy products? |
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Are you physically
inactive? |
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Do you exercise
regularly? |
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Do you exercise a
great deal with irregular or no
menstruation? |
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Is your diet high
in protein? |
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Do you salt you
foods? |
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Does your diet
consist mostly of vegetarian products? |
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Do you eat at fast
food restaurants (like drive threw)? |
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Do you move your
bowls regularly? |
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Do you regularly
drink coffee? |
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SECTION B.
Controllable Risk Factors Continued |
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Do you drink more
than one soda pop or carbonated
drink/daily? |
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Do you take
caffeine products such as Vivarin or
No-Doze regularly? |
SECTION C: Other Risk Factors:
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Did you have a
history of exposure to heavy metals?
Yes ___ No____
Where do you live
now:( )
Where did you grow up: ( ) |
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Is your percentage
of body fat lower than 10% of total
body weight? |
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Have you ever used
anticonvulsants? |
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Have you taken
Tagamet / Nexium / Prilosec? |
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Do you have a
thyroid condition such as
hyperparathyroidism? |
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Do you have kidney
stones? |
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Have you ever used
steroid (cortisone drugs) regularly? |
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Have you had
biliary cirrhosis (an inflammatory disease
of the bile system connecting
the liver and intestines)? |
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Do you have an
overactive thyroid condition with
symptoms such as fast pulse and heart
rate, loss of
weight, increased metabolism? |
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Have you had
stomach or small intestine diseases? |
SOURCES
OF STRESS IN YOUR LIFE.
Note Estrogen Dominant Yes’s No’s represent no
dominance
Yes / No |
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I have trouble
concentrating on my work. |
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It takes me forever
to make decisions. |
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I can’t seem to
stick to a job. |
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From the time I get
some place until I leave, I am
restless & want to leave. |
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I overreact to
things at work and at home. |
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I let minor things
get to me. |
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I procrastinate. |
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I can’t seem to get
organized. |
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I am unclear about
my role at work or home.. |
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I do a lot of paper
shuffling. YES or NO |
Anti-Aging Clinic Assoc., Inc., 954-742-4430
What demands are you making on your body?
Answer "Yes" or "No" to each of these questions.
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Yes |
No |
1. Are you being
treated for any disease or serious condition? |
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2. Is your work a
source of stress for you? |
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3. Do you Skip
meals or follow a popular diet plan? |
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4. Do you feel
overscheduled and rushed? |
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5. Are you taking
more than one prescription medication? |
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6. Do you
experience a lot of conflict or stress in your relationship? |
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7. Do you have
caffeine or soft drinks more than once a day? |
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8. Have you
experienced a major trauma or loss in the last 5 years? |
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What kind of support are you giving
your body?
Answer these "Yes" or
"No"
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Yes |
No |
1. Do you eat
protein at every meal? |
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2. Do you eat 4 or
more servings of fruit &
vegetables a day? |
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3. Do you minimize
simple carbohydrates,
alcohol and sweets? |
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4. Do you exercise
4 or more times a week? |
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5. Do you feel you
make adequate time for your
needs? |
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6. Do you take
high-quality nutritional
supplements? |
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7. Do you minimize
toxins and processed foods
in your diet? |
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1. Are you on traditional HRT Y / N or,
are you trying to wean
yourself off of it? Y / N 2. What is your age? _________
Notes and Recommendations for you
and your Physician
1. We will explain how to collect the saliva samples once we
have a
completed questionnaire delivered by hand or US Mail.
2. When you receive the saliva sample kit in person or through
the US
Mail; make a copy of the sample instruction sheet and
sample date box
for you to keep when sampling has been
completed; you will mail the
original with the sample to the
Laboratory, addressed on the box.
3. You will forward the original sample instruction sheet with
the
completed frozen sample collection vials, in the same
return box via,
Federal Express, to the address on the box
next day.
SALIVA SAMPLE
INSTRUCTION SHEET
4. After completed samples are mailed; in approximately 12
to 15 days
after the Laboratory receives the samples and
results of the tests are
established, copies will be mailed to
you and to our compounding
pharmacist. One of our
professionals will make a suggestive plan for you
and
contact you by phone. |
TO
SEE THE OVARIAN AND MENSTRUAL CYCLE CHART
1111
Click
Here to see the hormone pathway chart |
Client
consent for treatment
1111 |
Every client must read and sign the
authorization and release form in conjunction with this Questionnaire.
Authorization
and release
form is located at highlighted link provided.
Authorization
and release form
Every client must read and sign our
privacy policy located at the highlighted link:
1111
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 suggestion of out side
treatment and in house products described to me, to may satisfaction.
_________________________________________________
_______________________
Client
signature
Date
_________________________________________________
_______________________
Witness
signature
Date
THE WITNESS MUST BE A NOTARY IF SIGNED
OUTSIDE THE ANTI-AGING
CLINIC OFFICE.
When we receive this Questionnaire, Authorization and Privacy
Policy from
you, signed and executed,
we will call you for credit card information.
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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
for your authorization; all pages must be signed and mailed to the
Anti-Aging Clinic at 7200, West
Commercial Blvd., Suite 209, Lauderhill, Florida, 33319. |
[disclaimer] “These statements have not
been evaluated by FDA.
OSH is not intended to diagnose, treat, cure or
prevent any disease.”
Because of the unscrupulous advertising practices from
the manufacturers of inferior dietary products, the FDA & FTC have made it clear
that we may use the correct printed information that indicates rGH spray is
indeed Growth Hormone on our website but that no-one may use the word Growth
Hormone on the bottle containing the product for sale to the public; because we
must fly under the radar screen. We must use Growth Factor instead, which is
perfectly acceptable. We must also place the following statement on our website:
These statements have not been evaluated by the FDA
and are not intended to diagnose, treat, cure, mitigate or prevent any disease.
OverTheCounter Rejuvenis Max is produced according to the guidelines of the
Homeopathic Pharmacopeia of the United States. Furthermore, with respect to our
Rejuvenis Max and Somastatin products, in order to comply with current FTC
requirements, we must state all anti-aging benefits mentioned are associated
with the injectable form of somatotropin and not our OTC HPUS products.
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