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Services
Pricing
Testimonials
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Contact Us

(909) 206-2931

biological sex at birth

Step 1 of 17

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One More Step

Select your biological sex at birth so we can provide the most relevant intake form for you.

Untitled

Male

Female

Section 1 of 8 — Basic Information

Men's Testosterone & Hormone Optimization Intake

Estimated 5–7 minutes to complete

Basic Information

First Name*(Required)

First

Last Name(Required)

Last

Date of Birth*(Required)

MM slash DD slash YYYY

Email*(Required)

Phone(Required)

Height*(Required)

Weight (lbs)*(Required)

Do you have a primary care provider?(Required)

Yes

No

Occupation

Marital Status

Do you have children?

Yes

No

What is your biggest current stressor?

Section 2 of 8 — Basic Information

Men's Testosterone & Hormone Optimization Intake

Estimated 5–7 minutes to complete

Goals

What would you most like to improve? (select all that apply)

More energy

Weight loss

Improve libido

Improve erections

Build muscle

Reduce body fat

Better sleep

Better mood

Increase motivation

Brain fog

Athletic performance

Healthy aging

Hormone optimization

Other

Please explain

Section 3 of 8 — Basic Information

Men's Testosterone & Hormone Optimization Intake

Estimated 5–7 minutes to complete

Current Symptoms

Energy

Fatigue

Brain fog

Low motivation

Low stamina

Difficulty losing weight

Sexual Health

Low libido

Erectile dysfunction Difficulty

maintaining erections

Fewer morning erections

Decreased sexual performance

Physical

Loss of muscle

Increased body fat

Decreased strength

Decreased endurance

Hair loss

Joint pain

Muscle aches

Sleep

Trouble falling asleep

Wake frequently

Poor quality sleep

Snoring

Possible sleep apnea

Mood

Anxiety

Depression

Irritability

Mood swings

Difficulty concentrating

Other

Headaches

Heart palpitations

Heat intolerance

Cold intolerance

Constipation

Bloating

None of the above

Section 4 of 8 — Basic Information

Men's Testosterone & Hormone Optimization Intake

Estimated 5–7 minutes to complete

Hormone History

Have you ever used testosterone therapy?

Yes

No

Do you want to preserve fertility?

Yes

No

Unsure

History of prostate cancer?

Yes

No

Family history of prostate cancer?

Yes

No

Unsure

History of elevated PSA?

Yes

No

Unsure

Urinary symptoms:

Frequent urination

Weak urine stream

Waking at night to urinate

Difficulty starting stream

Blood in urine

None of the above

Section 5 of 8 — Basic Information

Men's Testosterone & Hormone Optimization Intake

Estimated 5–7 minutes to complete

Medical History

Have you ever been diagnosed with:

High blood pressure

Diabetes or prediabetes

High cholesterol

Heart disease

Thyroid disease

Sleep apnea

Anxiety

Depression

Autoimmune disease

Cancer

Blood clot or clotting disorder

Liver disease

Kidney disease

None of the above

Other medical conditions

Previous surgeries

Section 6 of 8 — Basic Information

Men's Testosterone & Hormone Optimization Intake

Estimated 5–7 minutes to complete

Lifestyle

Exercise frequency:

None

1–2 days/week

3–5 days/week

Daily

Diet style:

Standard American

Mediterranean

Low carb

Keto

Vegetarian

Other

Alcohol use:

None

Occasional

Weekly

Daily

Tobacco/Nicotine:

Never

Former

Current smoker

Vape

Sleep quality:

Excellent

Good

Fair

Poor

Stress level 1/10

Low stress High stress

Section 7 of 8 — Basic Information

Men's Testosterone & Hormone Optimization Intake

Estimated 5–7 minutes to complete

Medications, Supplements & Allergies

Current medications*

Current supplements or vitamins

Medication allergies*

Have you had labs completed within the last 6 months?

Yes

No

Unsure

Section 8 of 8 — Basic Information

Men's Testosterone & Hormone Optimization Intake

Estimated 5–7 minutes to complete

Have you recently experienced any of the following?

Chest pain

Shortness of breath

Fainting

Blood in urine

Difficulty urinating

Severe headaches

Vision changes

Heart palpitations

Swelling in legs

None of the above

Is there anything else you would like your provider to know?

Section 1 of 8 — Basic Information

Women's Hormone & Metabolic Intake Questionnaire

Estimated 5–7 minutes to complete

Basic Information

First Name*(Required)

First

Last Name(Required)

Last

Date of Birth*(Required)

MM slash DD slash YYYY

Email*(Required)

Phone(Required)

Height*(Required)

Weight (lbs)*(Required)

Do you have a primary care provider?(Required)

Yes

No

Occupation

Marital Status

Do you have children?

Yes

No

What is your biggest current stressor?

Section 2 of 8 — Basic Information

Women's Hormone & Metabolic Intake Questionnaire

Estimated 5–7 minutes to complete

GOALS

What would you most like to improve? (select all that apply)

Weight loss

More energy

Better sleep

Hormone balance

Improve libido

Better mood

Brain fog

Healthy aging

Muscle tone/strength

Hair or skin changes

Other

Section 3 of 8 — Basic Information

Women's Hormone & Metabolic Intake Questionnaire

Estimated 5–7 minutes to complete

Current Symptoms

Energy & Weight

Fatigue

Weight gain

Difficulty losing weight

Low motivation

Brain fog

Low stamina

Sleep

Trouble falling asleep

Wake frequently

Wake too early

Poor quality sleep

Snoring

Mood

Anxiety

Depression

Irritability

Mood swings

Difficulty concentrating

Hormonal / Female

Hot flashes

Night sweats

Low libido

Vaginal dryness

Pain with intercourse

Urinary leakage

Frequent urination

Irregular periods

Heavy periods

Painful periods

PMS symptoms

Physical

Hair thinning

Dry skin

Joint pain

Muscle aches

Headaches

Heart palpitations

Constipation

Bloating

Heat intolerance

Cold intolerance

None of the above

Section 4of 8 — Basic Information

Women's Hormone & Metabolic Intake Questionnaire

Estimated 5–7 minutes to complete

Women's Hormone History

Are you still having menstrual periods?

Yes

No

Irregular or unsure

Are you planning pregnancy within the next 12 months?

Yes

No

Unsure

Current birth control method

Are you currently using hormone therapy?

Yes

No

Personal history of breast cancer?

Yes

No

First-degree family history of breast cancer?

Yes

No

Unsure

Have you had a hysterectomy?

Yes

No

Last Pap smear (approximate date)

MM slash DD slash YYYY

Current birth control method

Are you age 40 or older?

Yes

No

Section 5 of 8 — Basic Information

Women's Hormone & Metabolic Intake Questionnaire

Estimated 5–7 minutes to complete

Medical History

Untitled

High blood pressure

Diabetes or prediabetes

High cholesterol

Thyroid disease

Heart disease

Autoimmune disease

Anxiety

Depression

Sleep apnea

PCOS

Endometriosis

Fibroids

Cancer

Blood clot or clotting disorder

Liver disease

Kidney disease

Migraine with aura

None of the above

Other medical conditions

Previous surgeries

Section 6 of 8 — Basic Information

Women's Hormone & Metabolic Intake Questionnaire

Estimated 5–7 minutes to complete

Lifestyle

Exercise frequency:

None

1–2 days/week

3–5 days/week

Daily

Diet style:

Standard American

Mediterranean

Low carb

Keto

Vegetarian

Other

Alcohol use:

None

Occasional

Weekly

Daily

Tobacco/Nicotine:

Never

Former

Current

smoker Vape

Sleep quality:

Excellent

Good

Fair

Poor

Stress level 1/10

Low stress High stress

Section 7 of 8 — Basic Information

Women's Hormone & Metabolic Intake Questionnaire

Estimated 5–7 minutes to complete

Medications, Supplements & Allergies

Current medications*

Current supplements or vitamins

Medication allergies*

Have you had labs completed within the last 6 months?

Yes

No

✓Unsure

Section 8 of 8 — Basic Information

Women's Hormone & Metabolic Intake Questionnaire

Estimated 5–7 minutes to complete

Safety Screening

Have you recently experienced:

Chest pain

Shortness of breath

Fainting

New breast lump

Nipple discharge

Abnormal vaginal bleeding

Severe pelvic pain

Severe headache

Vision changes

Heart palpitations

None of the above

Is there anything else you would like your provider to know?

Be-2

At Beauty Enhanced Aesthetics, we help women and men achieve lasting transformation through medically guided weight loss, hormone optimization, and regenerative aesthetic treatments.

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(909) 206-2931

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