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
Platelet Rich Therapy
Advanced Services
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

3182 Route 9 Suite 209 Cold Spring NY 10516

2686 W MAIN ST, SUITE 1N WAPPINGERS FALLS, NY 12590

249 MAIN ST, UNIT 103 BEACON, NY 12508

CALL US TODAY!

(845)-202-0520

Visit Our Wappingers Office Visit Our Beacon Office

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

men's health intake form

Contact Us

Free Text

PERSONAL

Name

Occupation

Pharmacy

DOB

Address

Phone Number

Allergies

Height

Weight

Free Text

SOCIAL HISTORY

Tobacco

Recreational Drug Use (Past or Present)

Alcohol Use (How many drinks a week)

Exercise (How many days a week and what type of exercise)

Diet (Typical Breakfast, Lunch & Dinner)

Sexually Active? Single or Multiple Partners?:

Discomfort w/ Intercourse?

History of STDs, HIV/AIDS?

Free Text

PAST MEDICAL HISTORY

Medical Conditions

Past Surgeries

Home Medications

Last Primary Care Visit

Last Colonoscopy (if applicable)

Last Ophthalmologist Visit (if applicable)

Last Dermatologist Visit (if applicable)

Last Dental Visit

Past Testosterone or PED usage

Free Text

FAMILY HISTORY (STATE FAMILY MEMBER)

Cancer

Heart Disease/Heart Attack

Stroke

Diabetes

High Blood Pressure

Thyroid Disease

Liver or Kidney Issues

Vascular Issues

Free Text

MENTAL HEALTH

Anxiety

Depression

Eating Disorders

Are you feeling unmotivated?

Do you have trouble sleeping?

Free Text

**MEN ONLY**

Do you have to get up at night frequently to urinate?

Has the force of your urination decreased?

Have you had any kidney, bladder or prostate infections in the past 12 months?

Do you have any problems emptying your bladder?

Do you have problems achieving or maintaining an erection?

Are your erections softer than they used to be?

Do you have problems ejaculating?

Do you have pain or swelling in your testicles?

Free Text

Do you have any concerns with any of the below signs or symptoms (Type YES/NO)

Low mood/Depression

Yes

No

Irritability

Yes

No

Anxiety

Yes

No

Anger

Yes

No

Discouragement

Yes

No

Decreased interest in activities or relationships

Yes

No

Decreased productivity at work

Yes

No

Decreased motivation/drive/initiative

Yes

No

Concentration problems

Yes

No

Memory problems

Yes

No

Foggy thinking

Yes

No

Lower libido/sex drive

Yes

No

Erection problems

Ye

No

Increased fatigue

Yes

No

Decrease in muscle mass

Yes

No

Decrease in athletic performance

Yes

No

Muscle soreness/fatigue

Yes

No

Decrease in strength

Yes

No

Joint problems

Yes

No

Elevated blood pressure

Yes

No

Blood sugar problems

Yes

No

Sweet/carb cravings

Yes

No

Caffeine Cravings

Yes

No

Increased fat on hips/abdomen/thighs/chest

Yes

No

Weight loss

Yes

No

Weight gain

Yes

No

Hair loss

Yes

No

Free Text

CONCERNS

**Let us know what made you reach out to us for our services**

Free Text

GOALS

**What are your goals for the next 12 months and how can we help you reach them**

Free Text

**Please indicate services you are interested in**

New Field:

Testosterone Replacement Therapy & or Peptide Therapy

Erectile Dysfunction Treatment

Growth Hormone Optimization

Nutritional Supplementation:

Anti-Aging Services & Hormone Balancing

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
Platelet Rich Therapy
Advanced Services
Let’s Get Started

3182 ROUTE 9 SUITE 209 COLD SPRING, NY 10516

2686 W MAIN ST, SUITE 1N WAPPINGERS FALLS, NY 12590

249 MAIN ST, UNIT 103 BEACON, NY 12508

PHONE

(845)-202-0520

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
Platelet Rich Therapy
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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