Become a MALE Testosterone/Low T Replacement Patient Thank you for your interest in BioBalance® Health. In order to determine if you are a candidate for Bioidentical testosterone pellets we need your laboratory results and history forms. Dr. Maupin or Dr. Sullivan will evaluate your information prior to your consultation to determine if BioBalance® Health can help you live a healthier life. If you are under the age of 18 you are not a candidate at this time. BioBalance Health is a practice dedicated to treating aging men with testosterone pellets, anti-aging medications, and supplements. We do not treat young men unless they have head injuries, Klinefelter's Disease, brain surgery involving the pituitary, or testicular surgery that leaves them without testosterone production. Please complete the following tasks before your appointment: 1. Fill out the online form below (you will be emailed the consent forms and lab requisitions), or print and complete the Men’s New Patient Packet (click here to download) and email, fax, or mail the completed questionnaire and signed consent forms to our office. 2. Have your blood lab drawn. Included are lab requisitions for Quest Laboratory, LabCorp, and there is a generic lab requisition if your insurance company does not cover Quest or LabCorp laboratories. You must fast for 12 hours and do not have sex for 48 hours prior to the blood draw. It is up to you to find out if your insurance company will cover the cost of the labs. If not, you may have your lab drawn at Quest at the BioBalance® Health discount (you will need to pay BioBalance® Health directly. PLEASE NOTE: It takes 2 weeks for us to receive the results in our office Once we receive ALL of your information and lab results, we will contact you to schedule your initial consultation. Thank you and we look forward to seeing you soon! BioBalance Health 10800 Olive Blvd. Creve Coeur, MO 63141 Attn: Receptionist Phone: (314) 993-0963 Fax: (314) 218-3999 Email: newpatient@biobalancehealth.comPATIENT INFORMATIONName* First Middle Last Home Phone*Cell Phone*Email* Social Security or Driver's License No.*Enter Address Information* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* Age*Which office will you be visiting?*Kansas CitySt. LouisEmployer:EMERGENCY CONTACT INFORMATIONReferred by:Occupation:Primary Care Physician:Emergency Contact Name:Emergency Contact Relationship:Contact's PhoneContact's Secondary Phone:Contact's Email CURRENT MEDICATIONSAre you currently taking any medications?*YesNoAllergies (List all allergies - Food, Drug, Other)List ALL the drug you are taking along with dosage and how often:*CURRENT SUPPLEMENTSAre you currently taking any supplements?*YesNoList ALL the supplements you are taking along with dosage and how often:*Symptoms of Hormonal Deficiencies (check all that apply) Lack Or Decreased Sex Drive ED: Erectile Dysfunction Decreased or No Ejaculation Loss of Morning Erections Insomnia Memory Loss/Trouble Thinking Loss of Motivation New Migraine Headaches Decreased Muscle Mass & Strength Joint Aches/Arthritis Lack of Energy - Fatigue Constipation Thinning Eyebrows Poor Immunity Exhausted In The Morning Can't Fall Asleep Poor Balance Poor Coordination Increased Belly Fat Ringing in Ears Thinning Hair Depression New Anxiety Attacks Male Breast Development Cold All The Time Generalized Swelling Brittle Nails Irritable Low Blood Sugar Stay Awake For Days Ache All Over Exercise History (Check all that apply) I Don't Exercise I Have A Physical Job I Exercise Daily I Exercise 3 Times/Week For 50 Min or More I Am A Long Distance Runner I Lift Weights Normal Activity is What I Consider Exercise How many minutes a day do you exercise?*How many times a week do you life weights?*Previous Testosterone Replacement (Check all that apply) I Have Used Pellet T Before I Have Used T Gel Before I Have Used Drugs I Have Used Anabolic Steroids To Gain Muscle I have Used/Still Use Growth Hormone Injections I Have Used Testosterone In Some Form Before List All Other Forms of Testosterone or Steroid UsePast Surgeries:* I've Never Had Surgery Lap Band Surgery or Obesity Surgery Open Heart Surgery Joint Replacement Cancer Surgery Vasectomy Other What year did you have Lap Band Surgery or Obesity Surgery?*What year did you have Open Heart Surgery?*What year did you have a joint replaced?*What year did you have Cancer Surgery?*What year did you have a Vasectomy?*What other surgeries have you had and what year did you have them?*Habits (Check all that apply) Smoking Cigarettes Or Cigars I Drink More Than 10 Drinks of Alcohol/Week I Drink Everyday I Have A Problem With Drinking I am a Recovering Alcoholic I Use or Have Used Marijuana In Past Year I Use or Have Used Cocaine If You Smoke, How Many Packs/Day And For How Many Years?If You Previously Smoked, How Many Packs/Day And For How Many Years?Family History (Check all that apply) Prostate Cancer Other Cancers Lung Cancer Breast Cancer (Female) Breast Cancer (Male) Obesity Heart Disease Heart Arrhythmias Thyroid Disease Arthritis Autoimmune Disease Diabetes Type I Diabetes Type II Hemochromatosis Preventative Medicine (Check all that apply) PCP Visit in Last Year Urologist Within Last Year Colonoscopy In Last 10 Years Medical Illnesses: Played Contact Sports Had a Concussion ADD or ADHD Addison's Disease Adrenal Fatigue Alcoholism, AA, Drug Dependence Arthritis Blood Clot/Pulmonary Embolism BPH: Benign Prostatic Enlargement Depression/Anxiety Diabetes Type I Diabetes Type II Emphysema / Copd Fatty Liver Disease Glaucoma Heart Attack Hemochromatosis Hepatitis High Blood Pressure HIV, AIDS Insulin Resistance Kidney Disease Manic Depression or Bipolar Disorder Multiple Sclerosis Narcolepsy Osteoporosis Past History Of Head Injuries Post Concussion Syndrome Restless Legs Schizophrenia Seizures or Epilepsy Sleep Apnea Stroke TB Prostate Cancer Testicular Cancer Other Cancer What year were you diagnosed with ADD or ADHD?*What year were you diagnosed with Addison's Disease?*What year were you diagnosed with Adrenal Fatigue?*What year were you diagnosed with Alcoholism, AA or Drug Dependence?*What year were you diagnosed with Arthritis?*What year were you diagnosed with a Blood Clot/Pulmonary Embolism?*What year were you diagnosed with BPH: Benign Prostatic Enlargement?*What year were you diagnosed with Depression/Anxiety?*What year were you diagnosed with Diabetes Type I?*What year were you diagnosed with Diabetes Type II?*What year were you diagnosed with Emphysema / Copd?*What year were you diagnosed with Fatty Liver Disease?*What year were you diagnosed with Glaucoma?*What year did you have a Heart Attack?*What year were you diagnosed with Hemochromatosis?*What year were you diagnosed with Hepatitis?*What year were you diagnosed with High Blood Pressure?*What year were you diagnosed with HIV, AIDS?*When did you become Insulin Resistance?*What year were you diagnosed with Kidney Disease?*What year were you diagnosed with Manic Depression or Bipolar Disorder?*What year were you diagnosed with Multiple Sclerosis?*What year were you diagnosed with Narcolepsy?*What year were you diagnosed with Osteoporosis?*Do you have a Past History Of Head Injuries?*What year were you diagnosed with Post Concussion Syndrome?*What year were you diagnosed with Restless Legs?*What year were you diagnosed with Schizophrenia?*What year were you diagnosed with Seizures or Epilepsy?*What year were you diagnosed with Sleep Apnea?*When did you have a Stroke?*What year were you diagnosed with TB?*What year were you diagnosed with Prostate Cancer?*What year were you diagnosed with Testicular Cancer?*What year were you diagnosed with Cancer?*Social History (Check all that apply) I Have Completed My Family I Am Married or in Committed Relationship I am Sexually Active I Want to be Sexually Active I Am Heterosexual I Am Homosexual I Am Bisexual Diet History (Check all that apply) I Eat Anything I Want I Don't Eat Much And Gain Weight Anyway I Have Gained Weight In My Abdomen I Eat A Balanced Diet 3 Times A Day I Eat 6 Small Meals A Day I Don't Eat Meat or Animal Products I Am Gluten Sensitive I Limit Carbohydrates I Eat Low Fat Diet High Protein Diet Other Type of other diet:*Electronic Signature* I attest that all the information I give is true. Additional Information
