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:__________

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: ______________________________________________________

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:____

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

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? ______________________

33. Where do you have cellulite? Hips-----Buttocks-----Thighs------Arms-----

Question #             Explanation:                                 

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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?___

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?_________ 

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

OSTEOPOROSIS ASSESSMENT:  
      Section A. Uncontrollable Risk Factors  / Answer Yes or
      leave blank for No

SECTION B. Controllable Risk Factors     

SECTION C: Other Risk Factors:    

  SOURCES OF STRESS IN YOUR LIFE.
  Note Estrogen Dominant Yes’s    No’s represent no
  dominance

   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.      

   What kind of support are you giving
   your body?

                                Answer these "Yes" or "No"                                               

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?  _________

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.