Become a MALE Testosterone/Low T Replacement, or Weight Loss Patient Thank you for your interest in BioBalance® Health. In order to determine if you are a candidate for Bioidentical testosterone pellets, or weight loss we need your laboratory results and history forms. Dr. Maupin or Dr. Sullivan will evaluate your information prior to your consultation to determine if BioBalance® Health can help you live a healthier life. If you are under the age of 18 you are not a candidate for Testosterone or weight loss at this time. BioBalance Health is a practice dedicated to treating aging men with testosterone pellets, anti-aging medications, and supplements. We do not treat young men with testosterone unless they have head injuries, Klinefelter's Disease, brain surgery involving the pituitary, or testicular surgery that leaves them without testosterone production. Please complete the following tasks before your appointment: 1. Either complete the online form below you will be emailed the consent forms and lab requisition, or print and complete the Men’s New Patient Packet (click here to download) and email, fax, or mail the completed questionnaire and signed consent forms to our office. The New Patient Packet contains all the necessary forms, and the lab requisition. 2. Have your blood lab drawn. After completing the new patient form below you will be emailed a lab requisition. You must fast for 12 hours and do not have sex for 72 hours prior to the blood draw. It is up to you to find out if your insurance company will cover the cost of the labs. If not, you may have your lab drawn at Quest at the BioBalance® Health discount (you will need to pay BioBalance® Health directly. PLEASE NOTE: It takes 2 weeks for us to receive the results in our office 3. Forward a copy of your most recent prostate exam to our office, if you have one. Once we receive ALL of your information and lab results, we will contact you to schedule your initial consultation. Thank you and we look forward to seeing you soon! BioBalance Health 10800 Olive Blvd. Creve Coeur, MO 63141 Attn: Receptionist Phone: (314) 993-0963 Fax: (314) 218-3999 Email: [email protected] Male Testosterone Replacement Fee Schedule: Initial Consultations – Physician (60 minutes) : $250 Follow up Consultations – Physician (60 minutes) : $250 Annual Treatment Plan Review $100 Male pellet insertion (every 4 to 6 months): Approximately $1,300 Weight Loss Fee Schedule: Consultations – Nurse Practitioners (45 minutes): $200 Follow-up Consultations – Nurse Practitioner: $150 If you are interested in both hormone replacement and weight loss they both will be covered in the same consultation. Purpose of Visit* Testosterone Replacement with Pellets Weight Loss Program Both Name* First Middle Last What do you prefer to be called (nickname)? Home PhoneCell Phone*Social Security or Driver's License No.* Email* Address (no PO Box):* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Age* Date of Birth* MM slash DD slash YYYY Referred by: Primary Care Physician: Urologist: Current or Previous Occupation: Employer Which office will you be visiting?* St. Louis Kansas City No Preference Preferred Pharmacy Name Preferred Pharmacy PhonePreferred Pharmacy Address Emergency Contact Name: Emergency Contact Relationship: Emergency Contact PhoneAre you taking any medications?* Yes No *Current Medications (List all current medications)Medication NameDoseFrequencyReason for Taking Are you taking any vitamins or supplements?* Yes No Current Vitamins & Supplements (List all current vitamins & supplements)Supplement Name and BrandDoseFrequencyReason for Taking Do you have any allergies (Food, Drug, Other)?* Yes No List all Allergies and Reactions (Food, Drug, etc.)AllergyReaction Current Symptoms (check all that apply)* Low or No Sex Drive (Libido) Fatigue or Lack of Energy ED: Erectile Dysfunction Loss of Morning Erections Decreased or No Ejaculation Depression Anxiety Change in Mood or Irritable Insomnia Memory Loss or Foggy Thinking Feeling Hopeless Low or No Motivation New Headaches Decreased Muscle Mass & Strength Joint Aches/Arthritis Dry Eyes Poor Balance & Coordination Weight Gain Belly Fat Male Breast Development Ringing in Ears Dry Skin Constipation Thinning Eyebrows Thinning Eyelashes Thinning Hair Cold All of The Time Swelling All Over Body Brittle Nails Ache All Over Poor Immunity Snoring Other: List all other symptoms*Marital Status* Married Divorced Separated Single Widowed Past Medical History (Check all that apply)* ADD or ADHD Addison’s Disease Adrenal Fatigue Alcoholism, AA, Drug Dependence Anxiety Arthritis Autoimmune Disease (specify diagnosis): Blood Clot/Pulmonary Embolism BPH: Benign Prostatic Enlargement Colon Cancer Cold Sores Concussion Contact Sports Cushing’s Disease Depression Pre-Diabetes Diabetes Type I Diabetes Type II Emphysema/COPD Fatty Liver Disease Fibromyalgia Glaucoma Heart Arrhythmia Heart Attack Heart Murmur Hemochromatosis Hepatitis Herpes High Blood Pressure High Cholesterol HIV or AIDS Hyperthyroid (overactive thyroid) Hypothyroid (under-active thyroid) Insulin Resistance or metabolic syndrome Klinefelter Syndrome Kidney disease Manic Depression or bipolar disorder Multiple Sclerosis (MS) Mumps Narcolepsy Osteopenia Osteoporosis Overweight or Obese Parkinson’s Disease Restless Leg Syndrome (RLS) Schizophrenia Seizures or Epilepsy Sleep Apnea Stroke Testicular Cancer Testicular Trauma (kick, punch, etc.) Tuberculosis (TB) I use oxygen I use a C-Pap machine Other Problems/cancers: List other medical history*Past Surgeries (Check all that apply)* None Gastric Bypass, Gastric Sleeve, Lap Band, or other weight loss surgery Joint Replacement Pacemaker Open Heart Surgery or Stents Gallbladder removed Prostatectomy Pain stimulator or any other implanted electrical device Vasectomy Other: List other past surgeries*I smoke Cigarettes/Cigars?* Yes No How many packs/day, how many years, and year you quit? I used to smoke Cigarettes/Cigars?* Yes No How many packs/day, for how many years? I Drink More Than 10 Drinks of Alcohol/Week* Yes No I am a Recovering Alcoholic* Yes No I Use or Have Used Marijuana in the past year* Yes No I Use or Have Used Cocaine in the past year* Yes No I Use or Have Used Heroin in the past year* Yes No I have used Anabolic Steroids in the past* Yes No List year anabolic steriod was used Social History (Check all that apply)* I have completed my family I still want to have children I am sexually active I want to be sexually active I do not want to be sexually active My sex life is good My sex life has gotten worse I am heterosexual I am homosexual I am bisexual I have a new partner in the last 3 years I have never had an orgasm Other: List All Other Social History*Previous Testosterone Replacement (Check all that apply)* None I Have Used T Pellet Before I Have Used T Gel Before I have used T Shots before I Have Used Testosterone before I have used Growth Hormone before Other: List All Other Forms of Testosterone Replacement*Family History of Autoimmune Disease*NoneMotherFatherSiblingChildrenFamily History of Blood Clots*NoneMotherFatherSiblingChildrenFamily History of Cancer, Breast*NoneMotherFatherSiblingChildrenFamily History of Cancer, Ovarian*NoneMotherFatherSiblingChildrenFamily History of Cancer, Prostate*NoneMotherFatherSiblingChildrenFamily History of Cancer, Testicular*NoneMotherFatherSiblingChildrenFamily History of Cancer, Other*NoneMotherFatherSiblingChildrenFamily History of Dementia*NoneMotherFatherSiblingChildrenFamily History of Diabetes, Type I*NoneMotherFatherSiblingChildrenFamily History of Diabetes, Type 2*NoneMotherFatherSiblingChildrenFamily History of Heart Attack or Stents*NoneMotherFatherSiblingChildrenFamily History of Other Heart Conditions*NoneMotherFatherSiblingChildrenFamily History of Hemochromatosis*NoneMotherFatherSiblingChildrenFamily History of Obesity*NoneMotherFatherSiblingChildrenFamily History of Prediabetes*NoneMotherFatherSiblingChildrenFamily History of Stroke*NoneMotherFatherSiblingChildrenFamily History of Suicide*NoneMotherFatherSiblingChildrenFamily History of Thyroid Disease – high or low*NoneMotherFatherSiblingChildrenList other family historyPreventative Medical Care (Check all that apply)* PCP Visit in Last Year Urologist Within Last Year Colonoscopy In Last 10 Years DEXA or Bone Density Scan in the last year Other: List other preventative medical careCurrent Diet (Check all that apply)* I eat anything I want I don’t eat much and gain weight anyway Gluten free Low carb Low fat Keto Intermittent Fasting Vegan Vegetarian Pescatarian Blood type specific diet Atkins/South Beach Weight Watchers Other: List other current diet planNumber of meals/snacks per day?* Current Exercise (Check all that apply)* None Cardio Weightlifting I have a very physical job I am a long distance runner, biker, or triathlete Other: Minutes of cardio per day/week? Minutes of weightlifting per day/week? Other current exercise: Height (ft, in)* Current Weight (lbs)* Goal Weight (lbs)* Current Pant Size Goal Pant Size *Do you have to take antibiotics for routine dental cleanings? Yes No Additional InformationElectronic Signature* I attest that all the information I give is true.
