Follow-up Medical Update Form Please enable JavaScript in your browser to complete this form.Follow-up Appointment Medical Update Form *Telehealth Requirement Patients must complete this form when following up with their prescribing physician, or corresponding with the clinic regarding any treatment related matter. Name *FirstLastEmail *What is the reason you are following up with us today ? *I am requesting dose adjustmentI want to get blood workI want to add another medication to my current treatment planI may be experiencing a side effect from my medicationI still have some symptoms that I'd like help resolvingI stopped using my medication and I want to resume treatmentI am submitting my follow-up blood workPlease provide us with any additional information as to why you contacted us today*You may leave this blank if it has already been noted aboveAge *Height *Weight *Please tell us about any new medications , or other medications you recently discontinued **Please enter "NONE" if this does not apply to you.Current medications prescribed by our clinic *Current dose (Per injection) *Injection frequency *Once a weekTwice a weekThree times a weekDailyYour Most Recent Lab Work Results - In the hours prior to having your blood collected, check all that apply to you *I exercised before my lab workI was not well hydrated (with water)I drank an energy drink or consumed coffeeI drank an electrolyte drink ( ex. gatorada or powerade)I work a physically demanding job and got my labs done on break or after workI had sex within 48 hours of my lab work.I was sick, or recovering from an illness (such as flu or cold)I consumed alcohol within 48 hours of lab workI was seated for an extended period of timeI was constipatedI performed an activity where I physically exerted myselfI was out in the sun all day (working, fishing, golfing etc)I was properly hydrated prior to having my blood drawn. *Proper hydration means you consume 1 gallon of water daily. (If you had blood drawn in the AM while fasted would mean you were NOT properly hydrated)I exercised before lab workDid you donate blood within the last 30 days ? *YesNoAre you currently experiencing a side effect from any medication prescribed to you by our clinic ? *YesNoPlease provide us with more details here if you need to*You may leave this blank if it has already been noted above having to by Are you currently experiencing any of these symptoms ? *No, I am not experiencing any of these symptoms at this time.Water retention in the hands or feetSwelling around the ankles that does not go away with restFeeling lethargicPain and swelling in 1 or both nipplesAbdominal (stomach) swellingTrouble breathing when lying downInability to achieve an erection (for more than 2 weeks)Loss of interest in sexTesticular atrophyOily skin that requires constant washingHot flashes that induce sweatingWaking up to urinate more than 2 times per night*Check the box next to any symptom that you experience consistently. Experiencing any of these symptoms "occasionally" or "briefly" are not typically concerning.Current Sexual Health - Select all that apply to you *I am satisfied with my sexual healthNot interested in sex at allNever have morning erectionsLow libidoCannot keep an erection during sex*Check the box next to any symptom that you experience consistently. Experiencing any of these symptoms "occasionally" or "briefly" are not typically concerning.Current Physical Health - Select all that apply to you *I am satisfied with my current physical healthGaining weight despite a healthy diet and routine exerciseEnlarged male breast tissue (gynecomastia)An increase in abdominal fat despite a healthy diet and routine exerciseLosing muscle strengthLosing muscle toneDeclining staminaAching jointsAching musclesPoor recovery after exerciseFatigue and tiredness even after proper rest*Check the box next to any symptom that you experience consistently. Experiencing any of these symptoms "occasionally" or "briefly" are not typically concerning.Current Mental Health - Select all that apply to you *I am satisfied with my current mental healthDifficulty concentratingDifficulty completing tasksConsistently depressedNo motivationBrain fogTimidNo desire to exerciseNo desire to eat healthyForgetfulOverly emotionalNo social life*Check the box next to any symptom that you experience consistently. Experiencing any of these symptoms "occasionally" or "briefly" are not typically concerning.Do you want us to contact you regarding today's follow up ? *YesNoToday's date *Signature * Clear Signature By signing: All questions were answered truthfulyl and are accurate to the best of your knowledge. You understand that the clinic may contact you to discuss your answers.*Medical Confidentiality: Superior Genetix Health & Wellness, Inc. does not share any part of your personal information, or medical history with any third party. All physicians and medically licensed staff are HIPAA Compliant. Submit
