Bradenton Office :

(941) 203-8944  

Las Vegas Office :

(702) 803-8222  

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Peak Male Institute

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New Patient Form

New Patient Form

Incoming New Patient Information

"*" indicates required fields

Step 1 of 5

20%

Male Patient Information

Your Name*
Todays Date*
Date of Last Physical Exam*
Date of Birth*
Address*
Your Email Address*
Primary Care Doctor (PCP)*
Emergency Contact*
Referred By:*
Choose all that apply.
Responsible Party*
Financially Responsible Person
Primary Number
Date of Birth*
Address*
Terms and Conditions*
Terms and conditions placeholder.

Male HRT Personal History

General:*
Check all that apply
Cardiovascular:*
Check all that apply
Gastrointestinal:*
Check all that apply
Genitourinary:*
Check all that apply
Psychiatric:*
Check all that apply
List your prescribed drugs and any over-the-counter drugs, such as vitamins and inhalers:*
List your prescribed drugs and any over-the-counter drugs, such as vitamins and inhalers:
Drug Name
Dosage
Frequency
Taken For
None
 
Allergies:*
Check all that apply
Allergies List:*
List any allergies and reactions.
Allergic to:
Reaction:
 
Surgeries*
Surgeries List:*
List any surgeries & reason for.
Year
Surgery:
Reason for:
 
Exercise:*
Check all that apply
Describe type of exercise and frequency (resistance training, cardiovascular, number of times per week, etc.):
Alcohol:*
Do you consume Alcohol in any form?
Estimate # of drinks per week regardless of type.
Tobacco:*
Illicit Drugs:*

Patient Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I have reviewed the Notice of Privacy Practices of Peak Male Institute.
Please check ONE of the following:*
Please read and initial ALL below:*
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Agreements and Authorizations: Consent to Release of Information

You authorize Peak Male Institute/Men’s Complete Health, LLC to release to government agencies, insurance companies, or other third-party payers and their agents, and its collection representatives and attorneys, the following “Patient Information”: medical history, diagnoses and procedures performed, course of treatment, plan of care, prognosis, supplies and/or such other information that may be requested for the purpose of determining eligibility and availability of Patient’s benefits, obtaining authorization/payment for Patient’s health care services, or billing and collection of amounts due to Peak Male Institute/Men’s Complete Health, LLC for services rendered. In the case of Patient Information released for purposes of payment of Patient Charges, this authorization shall be valid only for the period of time necessary to process payment claims. You further authorize any individual health care professional, including treating physician(s), to provide Peak Male Institute/Men’s Complete Health, LLC or its designee with Patient Information for quality assurance and, or risk management purposes. Finally, in the event that the Patient’s employer, or an insurance company representing such employer, request Patient Information relating to healthcare services provided for worker’s compensation injuries, it is understood and agreed that Peak Male Institute/Men’s Complete Health, LLC is required, under Florida law, to release copies of such information to such employer or insurance company without the authorization of Patient or Patient’s representative.
MM slash DD slash YYYY

SYMPTOMS OF LOW TESTOSTERONE LEVELS

Decreased concentration*
Difficulty learning new things*
Moodiness*
Depression*
Increasing fatigue*
Decreasing energy*
Daytime sleepiness*
Poor sleep habits*
Erectile dysfunction*
I have had testosterone checked previously*
I have used testosterone previously*
If Yes:
Date(s)
Type:
Usage:
 

Section Break

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ADAM questionnaire about symptoms of low testosterone

(Androgen Deficiency in Aging Male) This basic questionnaire can be very useful for men to describe the kind and severity of their low testosterone symptoms.
Do you have a decrease in libido (sex drive)?*
Do you have a lack of energy?*
Do you have a lack of energy?*
Have you lost height?*
Have you noticed a decreased “enjoyment of life” ?*
Are you sad and/or grumpy?*
Are your erections less strong?*
Have you noticed a recent deterioration in your ability to play sports?*
Are you falling asleep after dinner?*
Has there been a recent deterioration in your work performance?*

Male HRT or TRT Replacement Information & Consent

It is important to understand that medicine is an inexact science. Although we will carry out your treatment carefully, results may vary in their degree of success. It is quite natural for a patient undergoing Testosterone and or Hormone Replacement Therapy to want to know that everything will turn out all right. While most of the time this is the case, it is very important for you to be aware of the potential risks, as well as the benefits, expected from the treatment when deciding on whether to begin Hormone Replacement Therapy. You should also be aware of the alternatives to Testosterone and or Hormone Replacement Therapy, including not receiving the treatment. It is important that you consider the information we have provided you. Be sure that you are doing what is right for you. If you are unsure, then perhaps you should take some time to weigh your options or consult another health care provider. Please review the following statements, which discuss informed consent. Any questions that you may have should be brought to our attention. Your clinical provider will attempt to answer all your questions to your satisfaction.

Directions:

Read and Check each box beside every statement below.
By Checking each box I confirm that I have read each statement, understand and agree.*

Patient Signatures

By adding my signature below I confirm and agree that while a patient of Peak Male Institute (DBA-PMI) I will not take any type of anabolic steroids, testosterone gels, hormone “boosters,” pro- hormones or any additional testosterone supplementation not provided by Peak Male Institute (DBA-PMI) during my treatment plan. At any time, if use of these items is discovered, I understand I may be discharged as a patient of Peak Male Institute (DBA-PMI).
MM slash DD slash YYYY
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

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Peak Male Institute

©Peak Male Institute, 2023
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Bradenton Office

(941) 203-8944

6120 53rd Ave E
Bradenton, FL 34203

Las Vegas Office

(702) 803-8222

64 N. Pecos Road, Suite 106
Henderson, Nevada, 89074

IMPORTANT! All information presented in this website is intended for informational purposes only and not for the purpose of rendering medical advice. Statements made on this website have not been evaluated by the Food and Drug Administration and information contained herein is not intended to diagnose, treat, cure or prevent any disease.

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