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 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.  

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, 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:__________

 

Medical Information

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:____

       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

 

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-----

  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 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?_________ 

 

 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

 

___Increased breast size

 

___Suppression of
        lactation

 

 

  Headaches
 (where) Place "X" next to those
 relevant below

 

___Right side or

 

 

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

 

___Not at all

 Place an "X" beside each that is relevant                                                                                          

___Tiredness / Fatigue

___Decreased
       libido

___Could you nap in midday

___Vaginal
        dryness 

___Depression

___Painful
        intercourse

___Irritability & anxiety

___ Thickening of
        vaginal wall

 

 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

 

___Irregular
       heartbeat

 

___Rapid
       heartbeat

 

___Palpitations

 

Androgen Excess-Place "X"
next to those relevant:

____Acne
____Rashes
____Oily skin
____Increased appetite    
____Pruritis (itchy)
____Increased libido
____Hair loss
____Hair growing on face

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

 

 Mild
   1/3

Moderate/
Severe
    4/8

 Very Severe 9/10

None
  0

1. My menstrual
    periods are
     irregular
 

 

 

 

 

  

 

  

 

   

2. I have hot
     flashes or night
     sweats

 

 

 

 

 

 

 

3. I have insomnia
   or disturbed
    sleep

 

  

 

  

 

  

 

  

4. I feel very tired
   weary minded,
   no desire for
    effort.

 

  

 

  

 

  

 

  

 

 

   Mild
    1/3

Moderate/
Severe
         4/8

Very Severe
     9/10

 None
  0

5. I am irritable,
    sad, and
    apprehensive.

 

  

 

  

 

  

 

  

6. I feel that I’ve
    gained weight
    compared to last
    year.

 

  

 

  

 

  

 

  

7. My interest in sex
    isn’t what it used
     to be.

 

  

 

  

 

  

 

  

8. I crave sweets,
    carbohydrates or
    alcohol.

 

  

 

  

 

  

 

  

9. I suffer from
    vaginal dryness.

 

  

 

  

 

  

 

  

10. I have chilling
      sensations
 

1111

 

 

  

 

  

 

  

 

  

11. I have
      sensations of
       dizziness,
       swimming in
       head.

 

  

 

  

 

  

 

  

 

 

      Mild
     1/3

 Moderate/
   Severe
          4/8

  Very Severe
      9/10

  None
    0

12. I am anxious or
      have anxiety
      attacks.

 

  

 

  

 

  

 

  

13. I have
      headaches of
      any kind.

 

  

 

  

 

  

 

  

14. I feel stiff or pain
       in my joints,
       especially in the
       morning.

 

  

 

  

 

  

 

  

15. I sometimes
     feel over-
     whelmed or just
     not myself.

 

  

 

  

 

  

 

  

16. Sensations of
      numbness &/or
      tingling of the
      skin

 

  

 

  

 

  

 

  

17. I Feel like bugs
      are crawling on
      my skin.

 

  

 

  

 

  

 

  

18. I feel miserable
      and depressed.

 

  

 

  

 

  

 

  

 

 

Mild

Moderate/
Severe

Very Severe

None

19. Quick heart
      beat, fluttering,
      pounding,
      racing.

 

  

 

  

 

  

 

  

20. I have vaginal
    burning & itching.

 

  

 

  

 

  

 

  

21. Painful urination
      increased
      frequency

 

  

 

  

 

  

 

  

22. Leaking when,
      coughing,
      laughing,
      sneezing or
      hard work

 

  

 

  

 

  

 

  

 

23. Leaking when
       walking,
       running,
       climbing steps,
       or light work.

 

  

 

  

 

  

 

  

24. Leaking urine
      regardless of
      activity, even
      lying position.

 

  

 

  

 

  

 

  

 

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

 

Are you diabetic?

 

Do you have a family history of osteoporosis?

 

Are you Caucasian, Northern European or Asian?

 

 

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

 

Do you have a fair or light complexion?

 

Do you have a small-thin frame?

 

Are you over 40 years of age?

 

Are you over 70 years of age/

 

Have you had a full hysterectomy or had both ovaries
removed? (and your not taking replacement hormones) 

 

Did you breast-feed at least one child?

 

Do you have a dairy allergy or are you lactose intolerant?

 

Have you not had children?

 

Are you currently in or beginning menopause?

 

Have you lost any height? (2-points if ¼ inch, 4-points ½ or more)

 

Do you have low back pain or curvature?

 

Have you had a history of broken bones?

 

Do you get cramps in the legs or feet?

 

Do you experience bone pain?

 

Do you have brittle or soft nails?

 

Do you have premature graying of hair?

 

Do you have periodontal disease?

SECTION B. Controllable Risk Factors     

 

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

 

Is your diet deficient in vitamin D? Yes__ No__
If No, how much do you take_____

 

Do you smoke cigarettes?

 

Do you drink alcoholic beverages?

 

Do you avoid milk or other dairy products?

 

Are you physically inactive?

 

Do you exercise regularly?

 

Do you exercise a great deal with irregular or no
menstruation?

 

Is your diet high in protein?

 

Do you salt you foods?

 

Does your diet consist mostly of vegetarian products?

 

Do you eat at fast food restaurants (like drive threw)?

 

Do you move your bowls regularly?

 

Do you regularly drink coffee?

 

 

SECTION B. Controllable Risk Factors  Continued   

 

Do you drink more than one soda pop or carbonated
drink/daily?

 

Do you take caffeine products such as Vivarin or
No-Doze regularly?

SECTION C: Other Risk Factors:    

 

Did you have a history of exposure to heavy metals?
Yes ___ No____

Where do you live now:(                       )
Where did you grow up: (                        )

 

Is your percentage of body fat lower than 10% of total
body weight?

 

Have you ever used anticonvulsants?

 

Have you taken Tagamet / Nexium / Prilosec?

 

Do you have a thyroid condition such as
hyperparathyroidism?

 

Do you have kidney stones?

 

Have you ever used steroid (cortisone drugs) regularly?

 

Have you had biliary cirrhosis (an inflammatory disease
of the bile system connecting the liver and intestines)?

 

Do you have an overactive thyroid condition with
symptoms such as fast pulse and heart rate, loss of
weight, increased metabolism?

 

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

 

 

I have trouble concentrating on my work.

 

 

It takes me forever to make decisions.

 

 

I can’t seem to stick to a job.

 

 

From the time I get some place until I leave, I am
restless & want to leave.

 

 

I overreact to things at work and at home.

 

 

I let minor things get to me.

 

 

I procrastinate.

 

 

I can’t seem to get organized.

 

 

I am unclear about my role at work or home..

 

 

 

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.      

 

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 relationship?

 

 

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 minimize toxins and processed foods
    in your diet?

 

 

 

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.

  Click hereTO SEE THE OVARIAN AND MENSTRUAL CYCLE CHART        1111

Click hereClick 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.
Click hereAuthorization and release form

Every client must read and sign our privacy policy located at the highlighted link:    1111
Click here
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.
 

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.