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Drip Menu
Why Drip
Gallery
About Us
- Testimonials
Contact Us
Forms
Book Now

Patient Form

Restore, Replenish & Revitalize

New Patient Questionnaire

Name*
First Middle Last
Address
Street Address
Address
City State / Province / Region ZIP / Postal Code
Phone*
Email*
Height
Weight
Sex
- Male
- Female
Date of Birth
Date Format: MM slash DD slash YYYY
Age
Marital Status
Allergies:*
Medications, OTC, Vitamins:
Medical Conditions/Diseases(Please check all that apply)
- High cholesterol or lipids
- High blood pressure
- Diabetes
- Thyroid Disease
- Liver disease
- G6PD Deficiency
- Stroke
- Lung disease (ex:asthma, COPD)
- Ulcers
- arthritis or joint problems
- Depression
- Headaches/migraines
- Osteoporosis
Heart disease
- Heart disease
HIV – CD4
- HIV – CD4
Heart disease Type
HIV – CD4 Count
Cancer
- Cancer
Other
- Other
Cancer Type
Other Please list:
Do you have a history or family history of any of the following?
Cancer
- Yes
- No
Family Members
Heart Attack or Stroke:
- Yes
- No
Family Members
Have you had any of the following procedures/exams?
Vasectomy
- Yes
- No
Date/Result
Prostate/PAP exam
- Yes
- No
Date/Result
Colonoscopy
- Yes
- No
Date/Result
Hysterectomy/BTL
- Yes
- No
Date/Result
Sexually transmitted infections
- Yes
- No
Date/Result
Please answer the following questions
Do you have any children?
- Yes
- No
Do you plan to have more children?
- Yes
- No
Are you or your partner pregnantand/or breastfeeding?
- Yes
- No
Have you used steroids in the past?
- Yes
- No
Do you currently use steroids?
- Yes
- No
Are you currently sexually active?
- Yes
- No
Do you use any of the following?
Alcohol
- Yes
- No
If yes, how often and how much
Tobacco
- Yes
- No
If yes, how often and how much
Caffeine
- Yes
- No
If yes, how often and how much
Soy
- Yes
- No
If yes, how often and how much
Other
- Yes
- No
If yes, how often and how much
Do you have any problems with your sexual performance or vitality?
- Yes
- No
If yes, have you used any medications for it?
What did you use?
Did it help? If no, please explain.
Do you use nitrates for chest pain?
- Yes
- No
Please answer the followings questions:
Are you interested in anti-aging and preventive medicine?
- Yes
- No
If yes, please list your top goals in treatment:
Have you used any treatments in the past? Please List.
Do you Exercise?
- Yes
- No
If yes, please describe your routine.
Do you currently follow a special diet?
- Yes
- No
If yes, please explain.
Using Regenerative Medicine such as vitamin boosters, hormone replacement, and micronutrient therapy we can help you with mental and physical health, sexual vitality, prevention of disease, weight loss, and increased energy. Please let us know if you would like to learn more information or to schedule a free phone consultation of our services.
For communication purposes, please check how would like to be notified about appointments and special MedSpa offers.
- Phone
- SMS (text messages)
- Email
- All of above
Untitled
- I am not seeking medical treatment for any body enhancement, body building or performance enhancement of any kind.
- I am seeking this treatment for legitimate medical purposes.
- I will notify provider if I play any competitive sports and I accept all responsibilities for abiding by any rules and regulations that pertain to my sport. If unsure about sports medicine regulations, I will contact my team physician, appropriate sport association, and/or regulating board.
Comments
This field is for validation purposes and should be left unchanged.

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About Us

With our goals in mind we look to assist you to maintain or improve current state of good health. Prevent or minimize effects of colds or the flu or other viral illness.

Services

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Shots
Packages

Contact Information

2455 Ridge Rd #151
Rockwall, TX 75087

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