Microsoft word - the anabolic clinic tm prospective client form.05.doc

This questionnaire must be completed in its entirety. Just because you submit the completed questionnaire does not ensure that you will be accepted to The Anabolic Clinic, SC, as a client. Certain conditions prevent us from accepting you as a client because the anabolic substances currently available are contraindicated. If you have any of these conditions, do not submit a questionnaire or the other material: If you are a man with a history of untreated prostate cancer or breast cancer, currently available anabolic substances are contraindicated. We will not accept you as a client. If you are a woman with a history of breast cancer, are trying to get pregnant or have Polycystic Ovary Syndrome (PCOS) currently available anabolic substances are contraindicated. We will not accept you as a client. By submitting this questionnaire and other material to us, you acknowledge that the information you provide is true and correct. Do not forget to sign and date it (at the end of the questionnaire). Further, you agree to inform us within 5 calendar days of any change(s) in your condition, status or situation that would result in a different response to any of the information requested in this questionnaire. After submitting your completed, signed and dated questionnaire, it will be reviewed. You will be contacted by us. At that time we will inform you of whether you have been accepted as a client of The Anabolic Clinic, SC. If you have been accepted, we will schedule your consultation. Expect the consultation to last approximately one hour. Even if you are accepted, please note that should subsequent testing or the face-to-face consultation reveal that it is inappropriate for you to receive treatment with anabolic substances (in our sole discretion), we will not continue working with you. Payment in full is expected prior to your consultation. The Anabolic Clinic, SC, does not accept insurance for any of our services. At the time of your consultation, based upon the responses provided in your questionnaire, a proposed treatment and/or testing program will be offered and explained to you. This may be modified depending upon the information you provide during your consultation and/or the results of subsequent testing. Other material will be presented for you to sign at your consultation. If you decline to sign any of the forms, we will not work with you. Thank you for your interest in The Anabolic Clinic, SC. Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. Personal Demographics
______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ (if you are not a citizen, permanent resident or temporary working resident of the USA): Passport Number: ______________________________________________________ ______________________________________________________) ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ If we want to contact you, possibly with personal information: (circle one) May we leave a message for you on your home phone? May we leave a message for you on your personal mobile phone? Years of Education/highest degree: ______________________________________________________ Marital Status: (circle one) ______________________________________________________ ______________________________________________________ Who lives at home with you? ______________________________________________________ ______________________________________________________ ______________________________________________________ Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ If we want to contact you, possibly with personal information: (circle one) May we leave a message for you on your work phone? May we leave a message for you on your work mobile phone? ______________________________________________________ ______________________________________________________ ______________________________________________________ If we want to contact you, possibly with personal information: (circle one) May we send an email message to Email Address 1? May we send an email message to Email Address 2? May we send an email message to Email Address 3? Do you understand that we will not respond to emails sent to us? We require that all clients provide us a phone number with an answering machine or voice mail where we can leave a message containing personal information at any time. If you have indicated that none of the above is acceptable for leaving such a message, please provide us with a phone number with an answering machine or voice mail where we can leave personal information for you at any time: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. Medical Information
Primary Physician Information Physician Name: ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ Which of the following do you hope to have improved at The Anabolic Clinic, SC?
(please place a check mark (√) or an “X” in the column to the right of the item) Decreased desire and ability to exercise Increasing fat deposits about abdomen and/or thighs Other: Please use this space to explain “other” and write any additional information: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. FAMILY HISTORY
Please indicate with a check (√) family members who have had any of the following conditions:
Medical Condition Mom Dad Sister Brother Daughter Son Other
close
relatives
(Coronary Artery Disease) Heart Disease, Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. Pressure (Hypertension) High cholesterol Other: Please use this space to explain “other” and write any additional information: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. PERSONAL MEDICAL HISTORY
Date of Birth: ______________________________________________________ ______________________________________________________ ______________________________________________________ REVIEW OF SYSTEMS: Please check (√) any current problems you have on the list below.
___Air hunger (getting up at night feeling as if you need Other (please specify)___________________ Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. Do you have breast cancer or prostate cancer or liver disease? If “Yes,” please explain: ___________________________________________________________________________________ ___________________________________________________________________________________ PRESCRIPTION MEDICATIONS: Prescription medicines, including birth control pills, anti-coagulants,
diabetes medications, drugs for your heart, high blood pressure medications, performance-enhancing drugs by prescription. List ALL. Add additional sheets if needed: Medication
Times
per
day
Approximately how much do you spend monthly on prescription medications? NON-PRESCRIPTION MEDICATIONS: Non-prescription drugs, vitamins, home remedies, herbs, street
drugs, supplements, performance-enhancing drugs (w/o prescription), etc. Add additional sheets if needed: Medication
Times
per
day
Approximately how much do you spend monthly on non-prescription medications? Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. ALLERGIES or REACTIONS TO MEDICINES/FOODS/OTHER AGENTS:
Medicine, Food, Other
Reaction or Side Effect
MEDICATIONS and DRUGS: Do you take any of the following medications or drugs? If so, please provide
the dose and frequency. In the case of opiates or psychotropic drugs, please provide the name(s). Medication or Drug
Dose Times
Corticosteroids
(e.g., Aristocort, Atolone, Celestone, Celestone, Cortan, Cortizone, Cortone, Deltasone,
Entocort EC, Kenacort, Kenalog, Liquid Pred, Meticorten, Orapred, Orasone, Panasol-S,
Pediapred, Prednicen-M, Prelone, Soluspan, Sterapred)
Ketoconazole
(e.g., Nizoral, Extina, Xolegel, Kuric)
Finasteride
(e.g., Proscar, Propecia)
Spironolactone
(e.g., Aldactone, Novo-Spiroton, Aldactazide, Spiractin,Spirotone, Verospiron orBerlactone)
Flutamide
(e.g., Eulexin, Flutamide)
Cimetidine
Cyproterone
GnRH analogs
(e.g., Lupron)
Estrogens
(e.g., Premarin, Cenestin, Enjuvia)
Metoclopramide
(e.g., Metoclopramide, Reglan)
Ethanol
(e.g., beer, wine, spirits)
Opiates ____________________________________________________________________
Psychotropic drugs __________________________________________________________
Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. Do you currently have or have you ever had any of the following? If “YES,” please explain.
Please circle one
__________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Any known deficiency including minerals, vitamins __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Difficulty perceiving smells or fragrances __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________
SURGICAL HISTORY (Please list all prior operations or procedures and dates):

Operation or Procedure

MEN’S HISTORY:

Are you trying to have children?
Have you ever had a PSA (prostate specific antigen) test? YES If so, when?______________________________________________________ If so, was it abnormal? If it was abnormal, what was the value?_________________________________ If you had a PSA test, please provide a copy of the latest result and include it with this questionnaire.

If you have not had a PSA test within the last 3 months, we may request that you have one before offering
you treatment. Do you understand?

WOMEN’S HISTORY:

Are you pregnant?
________________________________________________ ________________________________________________ ________________________________________________ Number of therapeutic abortions (by choice): ________________________________________________ Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. 1st day, most recent period: (provide date) ____________________________________ Age at 1st period: ________________________________________________ Length of period: (actual bleeding - e.g., 5 days) Length of menstrual cycle: (e.g., 28 days; if irregular state range, e.g., 22-38 days) ________________________________________________________________________ Do you have any concerns about your periods? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Do you have any concerns about menopause? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Have you ever had a mammogram? YES If so, when?______________________________________________________ If so, was it abnormal? If it was abnormal, what was the result?________________________________________ ________________________________________________________________________ If you had a mammogram, please provide a copy of the latest result and include it with this
questionnaire.

If you have not had a mammogram within the last 6 months, we may request that you have one before
offering you treatment. Do you understand?
Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. SOCIAL HISTORY

Religion:
What is your religion: _______________________________________________________________________
Do you consider yourself observant of your religion? Does the observance of your religion place any dietary restrictions on you? If “Yes,” please describe: _____________________________________________________________________ __________________________________________________________________________________________
Tobacco Use:
Cigarettes:
Started (age) __________ Quit Date __________
Alcohol Use:
Do you drink alcohol?
Number of drinks per week: _________________________________________________ Is your alcohol use a concern for you or others? Have you ever felt the need to cut down on drinking? Have you ever felt annoyed by criticism of drinking? Have you ever had guilty feelings about drinking? Have you ever taken a drink first thing in the morning (Eye-openers) to steady your nerves or get rid of a hangover? Drug Use:
Do you use any recreational (street) drugs?
What drug(s) do you use: _____________________________________________________________________ Have you ever used needles to inject drugs?
Sexual Activity:
Have you been sexually active?
Current sex partner(s) is/are (circle all that apply): If you do not use birth control is that because none is needed? Birth control method(s) used: _________________________________________________________________ Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. Have you ever had any sexually transmitted diseases (STDs)? If “Yes,” what STD(s)? ______________________________________________________ Are you interested in being screened for sexually transmitted diseases? Caffeine Intake:
None:
_____ (check or place an “X” if none)
Weight and Height:
Are you satisfied with your weight? YES
Have you ever experienced an eating disorder? _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Are you pleased with your present eating habits? _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. Are you following a special diet or have you changed your diet in any way(s) over the last year? If “Yes,” what kind of diet? Check the one(s) that apply: If “Other,” please describe: _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ Do you eat or drink four servings of dairy or soy daily or take calcium supplements?
Exercise:
Do you “exercise” regularly?
What kind of “exercise”?__________________________________________________ ______________________________________________________________________ How long (minutes)? How often?____________________________________________ ______________________________________________________________________ If you do not “exercise,” why?______________________________________________ ______________________________________________________________________ Have you ever used performance enhancing drugs? If “Yes,” which, when, why?:_______________________________________________ _______________________________________________________________________ _______________________________________________________________________ Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved.
Safety:
Do you use a bike helmet?
If “Yes,” please describe:_________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Have you ever been abused? If “Yes,” please describe:__________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Do you own a gun?
Associations:
Do you belong to a gang?
If “Yes,” which gang?_____________________________________________
Legal: (add additional sheets if necessary)
Have you ever sued a medical doctor or other health care worker?
If “Yes”: (if more than once, please add additional sheet) Who?__________________________________________________________ Why?__________________________________________________________ When?_________________________________________________________ Where?_________________________________________________________ Did you prevail? Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved. Have you ever been convicted of a violent crime? When?__________________________________________________________ What?___________________________________________________________ ________________________________________________________________ Have you ever been convicted of a sex offense? When?__________________________________________________________ What?___________________________________________________________ ________________________________________________________________ When?__________________________________________________________ Why?___________________________________________________________ ________________________________________________________________ ________________________________________________________________ Have you ever had a restraining order issued against you?
If “Yes,” please describe:_________________________________________________
______________________________________________________________________
______________________________________________________________________
I hereby affirm that the above information is true and correct.
________________________________________
Your Name Printed
________________________________________
_______________________
Your Signature
Copyright 2009-2012. The Anabolic Clinic, S.C. All rights reserved.

Source: http://anabolicclinic.com/The%20Anabolic%20Clinic%20sm%20Prospective%20Client%20Form.05.pdf