Get Started Here Female Prefix: * Mrs.Ms. City: * First Name: * State: * ALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING Middle Initial: Zip: * Last Name: * Best Phone Number to Reach You: * Date of Birth: * ( MM/DD/YYYY ) Best Time to Call You: 01:0001:3002:0002:3003:0003:3004:0004:3005:0005:3006:0006:3007:0007:3008:0008:3009:0009:3010:0010:3011:0011:3012:0012:30 ampm E-mail: * Height: ( Ft ) Address 1:* Weight: ( Lbs ) Address 2: First Day of Last Menstrual Cycle: * ( MM/DD/YYYY ) What Are Your Chief Medical Complains? * What Do You Expect to Achieve With an Anti-Aging Treatment? * • BEHAVIOR NONE MILD MODERATE SEVERE Nervous Depressed Stress Irritable Anxious Mood Swings Tearful • MEMORY NONE MILD MODERATE SEVERE Foggy Thinking Memory Lapse • ENERGY NONE MILD MODERATE SEVERE Burned Out Feeling Morning Fatigue Evening Fatigue Decreased Stamina • HEART NONE MILD MODERATE SEVERE Rapid Heartbeat Heart Palpitations Slow Pulse Rate • BLOOD NONE MILD MODERATE SEVERE High Blood Pressure Low Blood Pressure High Blood Sugar Low Blood Sugar High Cholesterol Elevated Triglycerides • SEXUAL DRIVE NONE MILD MODERATE SEVERE Decreased Libido Vaginal Dryness Infertility Problems • MUSCLES NONE MILD MODERATE SEVERE Decreased Muscle Size • SKIN / HAIR / NAILS NONE MILD MODERATE SEVERE Acne Thinning Skin Hair Dry or Brittle Nails Breaking or Brittle • ACHES / PAIN NONE MILD MODERATE SEVERE Headaches Neck or Back Pain • OTHERS NONE MILD MODERATE SEVERE Sugar Cravings Sleep Disturbed Swelling or Puffy Eyes/Face Cold Body Temperature Numbness of Feet / Hands Goiter Bleeding Changes Sensitivity to Chemicals Bone Loss Allergies Hoarseness Rapid Aging Hearing Loss Loss Scalp Hair Increase Facial or Body Hair Weight Gain – Hips Weight Gain – Waist Water Retention Increased Urinary Urge Incontinence Constipation Hot Flashes Night Sweats Decreased Sweating Tender Breasts Fibromyalgia Fibrocystic Breasts Uterine Fibroids Do You Smoke? * YES NO Explain: Do You Drink Alcohol? * YES NO Explain: Do You Exercise? * YES NO Explain: Do You Wake Up Hungry? * YES NO Comments: Are You Hungry at Lunch Time? * YES NO Comments: What Do You Usually Eat During the Day? * Do You Feel Sleepy in the Afternoon? * YES NO Comments: Do You Fall Asleep Fast? * YES NO Comments: How Many Times do You Wake Up During the Night? * Explain: How Many Hours of Uninterrupted Sleep do You Get Per Night? * Do You Suffer From Chronic Skin Rash? * YES NO Comments: Do You Feel Wired at Bed Time? * YES NO Comments: How Did You Hear About Us? *
