Patient Intake Form | TRT National

Welcome to TRT National 👋 Let's find the right care for you.

What brings you in today?*

🔥 Weight Loss

💪 Testosterone / TRT

⚡ Energy & Vitality

❤️ Sexual Health

🧪 Vitamins & Nutrient Support

We've got you 💙 Let's grab a few quick details so our team can reach you.

Email*

Cell Phone (mobile)*

Date

MM slash DD slash YYYY

Please select an item from the following list:

First name*

Middle name or Initial

Last name*

Gender

Date of birth

MM slash DD slash YYYY

Other Phone

Address

Street Address Address Line 2 City State ZIP Code

Emergency contact name

First Last

Emergency contact relationship

Emergency contact phone

Let's quickly review your health — select anything that applies.

This field is hidden when viewing the form

Medical History

Do you have any of these conditions?

Start typing to search, and select all that apply.

Are you under a doctor's care at the present time?

If yes, for what?

A little medical background helps your provider care for you safely.

Surgeries & Other Hospitalizations

Reason/Diagnosis

Year

Hospital

Allergies

Allergies to medication

Please list any medications you have known allergies to:

Medication name

Purpose

Reaction

Prescribed Medications

Prescribed Medications, over-the-counter drugs, dietary supplements (include vitamins, inhalers, etc.)

Medication name

Dose

Frequency

Your daily habits help us personalize your plan.

Behavior Style: Please select which one best describes you

Which best describes your exercise habits?

Are you dieting now?

If yes, what diet program?

How many meals do you eat in an average day?

Rank your fat intake:

Rank your salt intake:

Rank your caffeine intake:

What types of caffeine do you drink?

Coffee

Tea

Soda

None

How many cups/cans per day?

Do you drink alcohol?

Do you use cocktail mixers?

If yes, what kind?

Cigarettes - packs/day?

Other Tobacco Products?

How many years?

Women Only - Are you pregnant, trying for pregnancy, or breast feeding?

Tell us a bit about your story, in your own words.

Weight History/Low Testosterone History

What is the main reason you decided to lose weight or begin TRT?

When did you begin gaining excess weight or feeling other symptoms of Low T? Provide reasons if known

What do you think is the main cause of your weight problems or low T?

Do you suffer from any of the following low testosterone symptoms: difficulty concentrating, Moodiness, Depression, Weight gain, decreasing sex drive, increasing fatigue, decreasing energy, daytime sleepiness, poor sleep habits, or erectile dysfunction?

What do you feel are your obstacle(s) to successful weight loss/healthy lifestyle?

Almost done! Please review and agree to the items below.

Consent for Treatment*

I have read and agree to the Consent for Treatment

TRT Consent & Risks*

I have read and agree to the TRT Consent & Risks

Medical History Accuracy statement*

I have read and agree to the Medical History Accuracy statement

HIPAA Privacy Notice*

I have read and agree to the HIPAA Privacy Notice

Terms & Conditions*

I have read and agree to the Terms & Conditions

Financial Policy*

I have read and agree to the Financial Policy

Signature — type your full name to sign*

By typing your name here, you agree this serves as your electronic signature.

Photo ID Upload

Max. file size: 32 MB.

Please upload a photo ID (driver's license preferred). We need this for your file and for any prescription of a controlled substance.

CAPTCHA

Alcohol Abuse
Anemia
Arthritis
Asthma
Bleeding Disorder
Bloody Stool
Bronchitis
Cancer
Chest Pain
Constipation
Convulsions
Depression
Diabetes
Diarrhea
Dizzy Spells
Drug Abuse
Eating Disorder
Epilepsy
Fainting Spells
Fatigue
Food Allergies
Frequent Urination
Gallbladder Disorder
Glaucoma
Gout
Headaches
Heart Disease
High Cholesterol
Hypertension
Insomnia
Irregular Pulse
Kidney Disease
Liver Disease
Lung Disease
Mental Illness
Migraines
Moodiness
Nervousness
Obesity
Palpitations
Rashes
Shortness of Breath
Sleep Apnea
Stroke
Thyroid Disease