Hormone Therapies | Beacon, NY | Pro-Health & Wellness

Serving Dutchess, Putnam, Orange and Westchester Counties

Home
Men’s Health
- Testosterone Therapy
- Peptide Therapy
Women’s Health
- Hormone Balancing
- Weight Loss
IV Vitamin Therapy
Sexual Wellness
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Let’s Get Started
- FAQ
- Patient Forms

PHILLIPSTOWN PLAZA

3182 Route 9 Suite 209 Cold Spring NY 10516

530 ROUTE 6, SUITE 1 MAHOPAC, NY 10541

Pro Health & Wellness

CALL US TODAY!

Visit Our Mahopac Office

Serving Dutchess, Putnam, Orange and Westchester Counties

Phillipstown Plaza

3182 Route 9 Suite 209 Cold Spring NY 10516

530 ROUTE 6, SUITE 1 MAHOPAC, NY 10541

CALL US TODAY!

Visit Our Mahopac Office

Home
Men’s Health
- Testosterone Therapy
- Peptide Therapy
Women’s Health
- Hormone Balancing
- Weight Loss
IV Vitamin Therapy
Sexual Wellness
Advanced Services
Let’s Get Started
- FAQ
- Patient Forms

Please answer these questions truthfully and to the best of your knowledge. This will allow us to design a treatment plan specifically designed for you. Your honest answers are greatly appreciated. If it does not apply, write N/A.

Contact Us

Free Text

Personal Health History

How did you hear about us?

* What are your goals for treatment? Do you have any specific concerns you would like addressed?

Please list any medical conditions you have been diagnosed with such as high blood pressure.

Surgeries:

Hospitalizations:

Have you ever been on testosterone replacement? Please describe your history of prescribed or illicit steroid use:

List any medications or supplements you are taking:

Please list any drug allergies you have:

Free Text

Health Habits

Exercise:

Exercise

Sedentary

Mild exercise

Option 3

Regular vigorous exercise

Are you dieting?

Please describe your alcohol intake:

Do you use tobacco? How much?

* Do you use any recreational or street drugs? If so, what?

Are you sexually active?

Yes

No

Any discomfort with intercourse?

Yes

No

Have you been diagnosed with HIV?

Yes

No

Free Text

Family Health History

* Please describe your family health history. Please include conditions such as prostate cancer, heart attacks, stroke, diabetes, high blood pressure etc. Please also include their age or if they are deceased

Father

Mother

Option 3

Paternal Grandfather

Maternal Grandmother

Maternal Grandfather

New option

New option

Unknown

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Mental Health

Do you feel depressed?

Yes

No

Do you feel depressed?

Yes

No

Do you have problems with eating or your appetite?

Yes

No

Do you feel unmotivated in life?

Yes

No

Do you have trouble sleeping?

Yes

No

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Men Only

Do you have to get up to urinate at night?

Yes

No

Do you have discomfort with urination?

Yes

No

Has the force of your urination decreased?

Yes

No

Have you had any kidney, bladder, or prostate infections within the last 12 months?

Yes

No

Do you have any problems emptying your bladder completely?

Yes

No

Do you have problems achieving or maintain an erection?

Yes

No

Are your erections softer than they used to be?

Yes

No

Do you have ejaculation issues?

Yes

No

Any testicle pain or swelling?

Yes

No

Date of last prostate and rectal exam

Please explain any yes answers from the previous questions or tell us anything else you would like us to know:

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Other recent problems:

Please check if you have any additional issues and briefly explain:

Skin

Head/Neck

Ears/Throat/Nose

Lungs

Chest/Heart

Joint/Muscle/Back

Gastrointestinal

Bladder

Mental health

Sexual health

Athletic performance

Recent changes in weight

Recent changes in energy levels

Recent changes in ability to sleep

Recent changes in libido or erection quality

New option

Not applicable

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Please rate each problem from a scale to 1-10, with 1 being never and 10 being often:

Irritability

Anger

Discouragement

Decreased interest in activities or relationships

Decreased productivity at work

Decreased motivation/drive/initiative

Concentration problems

Memory problems

Foggy thinking

Lower libido/sex drive

Increased fatigue

Decrease in muscle mass

Decrease in athletic performance

Muscle soreness/fatigue

Decrease in strength

Joint problems

Elevated blood pressure

Blood sugar problems

Sweet/carb cravings

Caffeine Cravings

Increased fat on hips/abdomen/thighs/chest

Weight loss

Weight gain

Hair loss

Anything else you would to mention

Free Text

Additional Services

* Please indicate services you are interested in:

Testosterone Replacement Therapy

Erectile Dysfunction Treatment

Growth Hormone Optimization

Nutritional Supplementation

Anti-Aging Services

Thank you for contacting us.
We will get back to you as soon as possible.

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Home
Men’s Health
Women’s Health
IV Vitamin Therapy
Sexual Wellness
Advanced Services
Let’s Get Started

Phillipstown Plaza

3182 ROUTE 9 SUITE 209 COLD SPRING, NY 10516

530 ROUTE 6, SUITE 1 MAHOPAC, NY 10541

PHONE

BUSINESS HOURS

By appointment only

Virtual Consultations Upon Request

Visa Payment Accepted

MasterCard Payment Accepted

American Express Payment Accepted

Discover Payment Accepted

Cash Payment Accepted

Check Payment Accepted

ACH

Home
Men’s Health
Women’s Health
IV Vitamin Therapy
Sexual Wellness
Advanced Services
Let’s Get Started

Phillipstown Plaza

3182 ROUTE 9 SUITE 209 COLD SPRING, NY 10516

530 ROUTE 6, SUITE 1 MAHOPAC, NY 10541

PHONE

BUSINESS HOURS

By appointment only

Virtual Consultations Upon Request

Visa Payment Accepted

MasterCard Payment Accepted

American Express Payment Accepted

Discover Payment Accepted

Cash Payment Accepted

Check Payment Accepted

ACH

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