Personal InformationName(Required) First Last What is your age?(Required)Phone(Required)Email(Required) Preferred Contact Method(Required) Phone Email Text Health & Hormonal HistoryDo you currently experience any of the following? (Check all that apply) Fatigue Low libido Irregular periods Hot flashes/night sweats Mood swings/anxiety Weight gain Brain fog/memory issues Brain fog/memory issues Sleep disturbances Select AllCurrent Menstrual Status: Regular cycle Irregular cycle Perimenopausal Menopausal/Postmenopausal Using birth control / hormonal therapy Select AllLast menstrual period (if applicable):Have you been diagnosed with any of the following? PCOS Endometriosis Endometriosis Adrenal fatigue Adrenal fatigue Other Select AllOther:(Required)Lifestyle & WellnessExercise frequency: None 1–2x/week 3–4x/week Daily Select AllSleep quality: Poor Fair Good Excellent Select AllStress level (1–10)Stress management practicesDiet type Standard Plant-based Keto/Low-carb Mediterranean Other Select AllOtherSupplements or Medications (list)Medical HistoryDo you currently have or have a history of any of the following? (Check all that apply) Heart disease Diabetes High blood pressure Sleep apnea Thyroid disorders Depression or anxiety Prostate issues (e.g., BPH or prostate cancer) Other Select AllOther(Required)Are you currently taking any medications or supplements? Yes No If yes, please list:(Required)Have you ever had your testosterone levels tested? Yes No Have you previously used testosterone therapy or hormone optimization? Yes No If yes, what type and when?(Required)Lifestyle & HabitsHow would you describe your energy levels? Excellent Good Fair Poor How many hours of sleep do you get per night? Less than 5 5–6 7–8 More than 8 Do you experience fatigue, especially in the afternoon? Yes No Vitality & Sexual HealthHave you noticed a decrease in any of the following? (Check all that apply) Libido (sex drive) Morning erections Sexual performance Confidence Mental clarity/focus Muscle strength or mass Motivation/drive Mood stability Select AllDo you experience:Difficulty maintaining erections? Yes No Premature ejaculation? Yes No Low interest in sexual activity? Yes No Goals & ExpectationsWhat are your primary goals in seeking hormone optimization or vitality support? (Check all that apply) Improve energy Boost libido Increase muscle mass Reduce fat Improve focus or mood Sleep better Overall well-being Other Select AllOther(Required)Availability for Scheduling MeetingsWhat Day(s) is good to meet?(Required) Monday Tuesday Wednesday Thursday Friday Saturday What time between 9:00 AM and 5:00 PM PST time is good for you?(Required) 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM PhoneThis field is for validation purposes and should be left unchanged.
