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NEW PATIENT QUESTIONNAIRE
Full Name
Email
Cell Phone Number
Home Address
Date of Birth
Age
Height
Weight
What are your three main goals for treatment?
Have you seen an Anti-Aging practitioner/physician before?
If yes, who?
If yes, what treatments/programs were prescribed?
Previous Hormone Treatments:
What made you decide to consult with Dr. Rusilko?
Did someone refer you?
Referral:
Do you consider your life stressful?
If yes, please describe:
What is your occupation?
Do you travel often?
Yes
No
Current prescribed medications:
Current over the counter medications:
Current vitamins/supplements:
Current Medical conditions:
High Cholesterol
High Blood Pressure
Heart Disease/Angina
Stroke
Allergies/Eczema
Thyroid Disease
Autoimmune Disorder
Rheumatoid Arthritis
Arthritis/Osteoarthritis
Anemia
Cancer
Chronic Fatigue
Type 1 Diabetes
Type 2 Diabetes
Hepatitis
Gout
Digestive Disorders
Reflux/GERD
Prostate Enlargement/BPH
Pulmonary/Respiratory
Disorders/Asthma
Osteoporosis/Osteopenia
Neurological Disorders
Major Depression
Anxiety
Have you noticed a change in the health of your hair, skin, or nails?
Yes
No
If yes, please describe:
Have you taken any steroids in the last 30 days? (e.g. testosterone, prednisone, cortisone)?
Yes
No
If yes, please describe:
Allergies:
Past Medical conditions (difficult pregnancies, hospitalizations, major illness):
Past Surgeries:
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