Male Lifestyle Questionnaire

Page 1 of 17

New Patient Contact

Mailing Address

Background Information

Date of Birth

Occupational Profile

Your Household

Your BHRT Goals

Please describe your expectations and goals as a patient at RejuvinAge.

Medications & Supplements

Do you have any medication allergies?

Yes

Please select...

Are you currently taking any medication(s)?

Yes

Please select...

Are you currently taking any supplements?

Yes

Please explain...

Health & Lifestyle

What is your daily water consumption?

Please select...

What is your daily caffeine consumption?

Please select...

Are you a tobacco user?

Currently use

Previously used

Never used

Please select...

Do you consume alcohol?

Currently use

Previously used

Never used

Please select...

Do you take recreational drugs?

Currently use

Previously used

Never used

Please select...

Male Hormone Quiz Cont'd

How often have you had a sensation of not completely emptying your bladder after urinating?

Please select...

How often have you had to urinate again less than 2 hours after you have finished urinating?

Please select...

How often have you found you stopped and started again several times while urinating?

Please select...

How often have you found it difficult to postpone urination?

Please select...

How often have you experienced a weak or slow urinary stream?

Please select...

How often have you had to push or strain to begin urination?

Please select...

How many times do you most typically get up to urinate?

Please select...

Benign Prostatic Hyperplasia (BPH) diagnosis?

Yes

Please select...

Have you used hormone replacement?

Yes

Please select...

Bioidentical Hormone Replacement Therapy

Before today, how long have you been considering or researching BHRT?

Under 30 days

2-5 months

6-12 months

Over 12 months

Please select

How did you first learn about RejuvinAge?

Payment Information

Cardholder Name

Cardholder Email Address

Card Number

Card Expiration

Invalid Input

Security Code

Charge Amount

$0.00

Terms of Enrollment

Prior to processing payment, please review the following terms:

Pre-paid consultations are non-refundable but may be rescheduled.
By proceeding, your credit or debit card will be charged.

I understand program appointments require in-person visits to our Virginia Beach clinic however initial consultations may be conducted remotely upon request.

I agree to RejuvinAge's patient appointment and refund policies.

You must agree to terms to proceed.

New Patient Contact

Mailing Address

Background Information

Your Household

Your BHRT Goals

Medical History

Medical History Cont'd

Tests & Examinations

Medications & Supplements

Health & Lifestyle

Health Survey

Health Survey Cont'd

Health Survey Cont'd

Health Survey Cont'd

Male Hormone Quiz

Male Hormone Quiz Cont'd

Male Hormone Quiz Cont'd

Bioidentical Hormone Replacement Therapy

Payment Information

Terms of Enrollment

For Women

For Men

BHRT Resources

Privacy & Use

New Patient Contact

Mailing Address

Background Information

Your Household

Your BHRT Goals

Medical History

Medical History Cont'd

Tests & Examinations

Medications & Supplements

Health & Lifestyle

Health Survey

Health Survey Cont'd

Health Survey Cont'd

Health Survey Cont'd

Male Hormone Quiz

Male Hormone Quiz Cont'd

Male Hormone Quiz Cont'd

Bioidentical Hormone Replacement Therapy

Payment Information

Terms of Enrollment

For Women

For Men

BHRT Resources

Privacy & Use

Keep Connected