Home
About Us
Forms
Patient Questionnaire
Patient Questionnaire for Weight Loss
Blogs
HRT
Contact us
(888) 333-8629
Mail
Patient Questionnaire
Giovane Medical Patient Questionnaire
Step
1
of
6
16%
About You
First Name
(Required)
First
Last Name
(Required)
Last
Sex
Shipping Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
(Required)
Your Email Address
(Required)
Email Address
Confirm Email Address
Date of Birth
MM slash DD slash YYYY
Driver's License Number
Referred by
Family History
Mother's Age
Mother's Current Health
Father's Age
Father's Current Health
Brothers Ages
Brothers Current Health
Sisters Ages
Sisters Current Health
Children's Ages
Children's Current Health
Marital Status
Single
Married
Separated
Divorced
Family Medical History
*All fields of information are required in this section
Thyroid Disorder
(Required)
Yes
No
Endocrine Disorder
(Required)
Yes
No
Hypertension
(Required)
Yes
No
Lipid Disorder
(Required)
Yes
No
Cardiovascular Disease
(Required)
Yes
No
Prostate Cancer
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Other Forms of Cancer
(Required)
Yes
No
Explain Yes Answers*
(Required)
*If not applicable, type NA or NONE
Nutritional History
Are you a vegetarian?
Yes
No
If you are a vegetarian, what food source do you rely on for protein in your diet?
What is your typical Breakfast?
What is your typical Morning Snack?
What is your typical Lunch?
What is your typical Afternoon Snack?
What is your typical Dinner?
What is your typical Evening Snack?
Please list the specific Vitamins and other supplements you currently take:
Work History
What is your occupation?
How long in this position?
*in years
Are you happy with your present employment?
Yes
No
If no, please explain
Do you travel frequently?
Yes
No
Please rate the stress level of your job
Low
Moderate
High
Exercise History
Do you have a gym membership?
Yes
No
If so, Where?
Do you have a personal trainer?
Yes
No
Do you?
Run
Jog
Fast Walk
Do you compete in organized sports?
Yes
No
What kind of exercises do you enjoy? (Check any that apply)
Group Aerobics
Weight Training
Swimming
Cycling
Rollerblading
Climbing
Hiking
Tennis
Golf
Other
Personal History
Please rate the level of stress in your home:
Low
Moderate
High
What do you do for relaxation or stress reduction?
Would you describe yourself as (Check as many that apply)
Happy
Content
Just Making It
Struggling
Depressed
Energetic
Physically Fit
Out of Shape
Just Plain Worn Out
A Natural Leader
A Team Player
Work Best in a Structured Environment
A Victim
Medical History
Height
Weight
Weight One Year Ago
Weight you would like to be
Surgeries you have had:
Current Medications
Add
Remove
Medications or foods you are ALLERGIC to:
Name and Location of your Primary Physician:
Treatments you have recieved fo illnesses or injuries in the last year:
Do you smoke or chew tobacco?
Yes
No
How Much?
How Long?
Do you drink alcoholic beverages?
Yes
No
How Much?
In what form?
Your general health today is:
Excellent
Good
Fair
Poor
*All fields of informaion are required in this section
1. Carpal Tunnel Syndrome?
(Required)
Yes
No
2. Blood Disorder
(Required)
Yes
No
3. Cancer
(Required)
Yes
No
4. Immune Disorders
(Required)
Yes
No
5. Poor Wound Healing
(Required)
Yes
No
6. Edema/excess fluid retention
(Required)
Yes
No
7. Hyperlipidemia or an elevation of lipids in the bloodstream.
(Required)
Yes
No
*These lipids include cholesterol and triglycerides
8. Upper Respiratory
(Required)
Yes
No
9. Lung Disorder
(Required)
Yes
No
10. Hypertension
(Required)
Yes
No
11. Are you taking Nitrates?
(Required)
Yes
No
12. Renal Disease
(Required)
Yes
No
*Renal failure is the condition in which the kidneys fail to function properly
13. Emotional Disorders
(Required)
Yes
No
14. Genital-Urinary Disorder
(Required)
Yes
No
15. Glaucoma
(Required)
Yes
No
Please Explain Yes Answers:
(Required)
SELF EVALUATION OF AGING BIOMARKERS
*Please check the appropriate boxes that best describe your current functional levels.
Mental Functions:
1. Spells of mental fatigue, inability to concentrate; feeling burned out:
Not Me!
Moderate
Often
2. Tired or sleepy in the afternoon or early evening:
Not Me!
Moderate
Often
3. Less mentally sharp, limited attention, not as witty:
Not Me!
Moderate
Often
4. Change in creativity or spontaneous new ideas:
Not Me!
Moderate
Often
5. Decrease in initiative to start new projects:
Not Me!
Moderate
Often
6. Decrease in interest in past hobbies or new work-related activities:
Not Me!
Moderate
Often
7. Decrease in competitiveness:
Not Me!
Moderate
Often
8. Change in memory function; increased forgetfulness:
Not Me!
Moderate
Often
9. Feelings of depression; a sense that work, marriage, or Recreational activities have lost significance:
Not Me!
Moderate
Often
Metabolic Functions:
10. Unexplained weight gain, particularly in the midsection:
Not Me!
Moderate
Often
11. Increased fat distribution in hips or breast area:
Not Me!
Moderate
Often
12. Increase in cholesterol or triglycerides:
Not Me!
Moderate
Often
13. Decrease in HDL cholesterol:
Not Me!
Moderate
Often
14. Rise in blood sugar levels or onset of diabetes:
Not Me!
Moderate
Often
15. Rise in blood pressure or diagnosed as "hypertensive":
Not Me!
Moderate
Often
16. Chest pain, diagnosis of "heart disease" or "blockage in arteries":
Not Me!
Moderate
Often
17. Shortness of breath with activity, asthma or emphysema:
Not Me!
Moderate
Often
18. Lightheadedness, dizzy spells, ringing in the ears, new headaches:
Not Me!
Moderate
Often
19. Poor circulation in legs, swelling of ankles, varicose veins, Hemorrhoids:
Not Me!
Moderate
Often
Physical Conditioning:
20. "Sore body syndrome", aches, joint and muscle pains:
Not Me!
Moderate
Often
21. Decline in flexibility and mobility; increased stiffness:
Not Me!
Moderate
Often
22. Decrease in muscle size, tone, strength:
Not Me!
Moderate
Often
23. Decrease in physical stamina:
Not Me!
Moderate
Often
24. Decrease in athletic performance:
Not Me!
Moderate
Often
25. Back pain, neck pain:
Not Me!
Moderate
Often
26. Tendency to pull muscles or get leg cramps:
Not Me!
Moderate
Often
27. Development of osteoporosis or inflammatory arthritis:
Not Me!
Moderate
Often
Sexual Functions (Men)
28. Decreased libido or desire for sex:
Not Me!
Moderate
Often
29. Decrease in spontaneous early morning erections:
Not Me!
Moderate
Often
30. Difficulty in maintaining a full erection:
Not Me!
Moderate
Often
31. Decrease in volume of ejaculate or semen:
Not Me!
Moderate
Often
Sexual Functions (Women)
32. Decreased libido or desire for sex:
Not Me!
Moderate
Often
33. Vaginal Dryness:
Not Me!
Moderate
Often
34. Vaginal Atrophy (Shrinking of Tissues):
Not Me!
Moderate
Often
Giovane Medical Services Incorporated
CONSENT FOR HORMONE REPLACEMENT THERAPY
(Required)
By signing this CONSENT, you agree that Giovane Medical and Their affiliates have your permission to manage your program of longevity medicine, utilizing nutritional guidance, exercise programs, natural supplements and hormone replacement therapy as deemed necessary.
All therapeutic procedures involve some risk, including failure to receive the desired result or to obtain the information sought. Although your doctor is the best source of information as to the risks involved, Giovane Medical is a partnership between doctor and patient which requires you to accept designated responsibility for carrying out your part of the program. Please be sure that you receive or request full information before signing this form. You are entitled to be fully informed by your doctor about the nature of the therapy, it’s purpose, it’s anticipated benefits, possible side effects, available alternatives, independent economic interests of your doctor, if any, and all known or reasonably foreseeable risks involved.
Your signature on this CONSENT means: (1) You have read and understand the information contained herein; (2) you will be informed by your physician about the nature and risks of this therapy; (3) you will be provided with an opportunity by your physician to ask questions about the nature and risks; (4) you have received all the information you desire about this therapy; and (5) you consent to the hormone replacement therapy program.
I agree to the privacy policy.
Print Name
(Required)
First
Print Name
(Required)
Last
Today's Date
(Required)
MM slash DD slash YYYY
Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
