Become a MALE Testosterone/Low T Replacement, or Weight Loss Patient Thank you for your interest in BioBalance® Health. In order to determine if you are a candidate for Bioidentical testosterone pellets, or weight loss 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 for Testosterone at this time, but could be a weight loss candidate. BioBalance Health is a practice dedicated to treating aging men with testosterone pellets, anti-aging medications, and supplements. We do not treat young men with testosterone 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. Either complete the online form below you will be emailed the consent forms and lab requisition, 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. The New Patient Packet contains all the necessary forms, and the lab requisition. 2. Have your blood lab drawn. After completing the new patient form below you will be emailed a lab requisition. You must fast for 12 hours and do not have sex for 72 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 3. Forward a copy of your most recent prostate exam to our office, if you have one. 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.com Male Testosterone Replacement Fee Schedule: Initial Consultations – Physician (60 minutes) : $250 Follow up Consultations – Physician (60 minutes) : $250 Annual Treatment Plan Review $100 Male pellet insertion (every 4 to 6 months): Approximately $1,300 Weight Loss Fee Schedule: Consultations – Nurse Practitioners (45 minutes): $200 Follow-up Consultations – Nurse Practitioner: $150 If you are interested in both hormone replacement and weight loss they both will be covered in the same consultation. What is the purpose of your visit*Hormone ReplacementWeight Loss ProgramBoth Hormone Replacement and Weight Loss ProgramName* First Middle Last Home Phone*Cell Phone*Email* Social Security or Driver's License No.* Home 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* MM slash DD slash YYYY Age* Which office will you be visiting?* Kansas City St. Louis Referred by: Employer: Occupation: Work 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 Primary Care Physician: Urologist: Emergency Contact Name: Emergency Contact Relationship: Emergency Contact PhoneEmergency Contact Secondary Phone:Emergency Contact Email Do you have any allergies (Food, Drug, Other)?* Yes No List all allergies and reactions*Are you currently taking any medications?* Yes No List all medications, dose, and frequency*Are you currently taking any supplements?* Yes No List all supplements, dose, and frequency*History of present illness/symptoms (check all that apply)* Low or No Sex Drive (Libido) Fatigue or Lack of Energy Erectile Dysfunction (ED) Loss of Morning Erections Decreased or No Ejaculation Depression Anxiety Change in Mood or Irritable Insomnia Memory Loss or Foggy Thinking Feeling Hopeless Low or No Motivation New Migraine Headaches Decreased Muscle Mass & Strength Joint Aches/Arthritis Poor Balance & Coordination Dry Eyes Weight Gain Belly Fat Male Breast Development Ringing in Ears Dry Skin Constipation Thinning Eyebrows/Eyelashes Thinning Hair Cold All of The Time Swelling All Over Body Brittle Nails Ache All Over Poor Immunity Snoring OTHER SYMPTOMS: List all other symptoms*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 Other Exercise List other exercise activity* How many minutes a day do you exercise?* How many times a week do you life weights?* Previous Testosterone Replacement (Check all that apply)* No History of Testosterone Replacement I Have Used T Pellet Before I Have Used T Gel Before I Have Used Anabolic Steroids To Gain Muscle I have Used/Still Use Growth Hormone Injections Other Testosterone Replacement List All Other Forms of Testosterone or Steroid Use*Past Medical History* ADD or ADHD Addison's Disease Adrenal Fatigue Alcoholism, AA, Drug Dependence Arthritis Autoimmune Disease (Rheumatoid, Lupus, etc.) Blood Clot/Pulmonary Embolism BPH: Benign Prostatic Enlargement Colon Cancer Concussion Contact Sports Cushing’s Disease Depression/Anxiety Diabetes Type I Diabetes Type II Emphysema / COPD Fatty Liver Disease Glaucoma Heart Arrhythmia Heart Attack Heart Murmur Hemochromatosis Hepatitis High Blood Pressure High Cholesterol HIV or AIDS Hyperthyroid Hypothyroid Insulin Resistance Kidney Disease Manic Depression or Bipolar Disorder Multiple Sclerosis (MS) Mumps Narcolepsy Osteopenia or Osteoporosis Overweight or Obese Prostate Cancer Restless Leg Syndrome (RLS) Schizophrenia Seizures or Epilepsy Sleep Apnea Stroke Testicular Cancer Testicular Trauma (kick, punch, etc.) Tuberculosis (TB) OTHER: List other past medical history*Surgical History (check all that apply) None Gastric Bypass, Lap Band, or Other Surgery for Weight Loss Joint Replacement Open Heart Surgery or Stents Pacemaker Prostatectomy Vasectomy OTHER: List other surgical historyFamily History - Mother/Father/Sister Brother (Check all that apply)* Autoimmune Disease Blood Clots Breast Cancer Colon Cancer Dementia Diabetes, Type I Diabetes, Type 2 Heart Attack or Heart Disease Hemochromatosis Obesity Prediabetes Prostate Cancer Stroke Testicular Cancer Thyroid Disease – high or low OTHER FAMILY MEDICAL PROBLEMS OR CANCERS: List other family history*Preventative Medicine (Check all that apply) PCP Visit in Last Year Urologist Within Last Year Colonoscopy In Last 10 Years Social History (Check all that apply) I am still fertile I have completed my family I am married or in a committed relationship I am sexually active I want to be sexually active I am heterosexual I am homosexual I am bisexual Do you use Oxygen?*NoYesDo you use a C-Pap Machine?*NoYesI smoke cigarettes or cigars*NoYesIf you smoke how many packs/day/# of years? I used to smoke cigarettes or cigars*NoYesIf you previously smoked, how many packs/day/# of years? I drink more than 10 drinks of alcohol/week*NoYesI use or have used marijuana in the past year*NoYesI use or have used cocaine*NoYesDiet 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 do not eat wheat (gluten sensitivity/intolerance) I eat a low carb diet I eat a low-fat diet I eat 3 meals a day I eat 6 small meals a day Vegan/Vegetarian Intermittent Fasting Keto Diet Atkins/South Beach Diet Weight Watchers Other/Previous Diets Tried: Other diets tried* Current Weight Goal Weight Current Shirt/Pant Size Goal Shirt/Pant Size Electronic Signature* I attest that all the information I give is true. Additional Information
