Male Hormone Consultation EmailThis field is for validation purposes and should be left unchanged.Are You Currently a Florida Resident? Yes, I am a Florida Resident.Date(Required) MM slash DD slash YYYY Personal InformationName(Required) First Last Are you a current patient of Barclay's Apothecary Shoppe?(Required) Yes No Date of Birth(Required) MM slash DD slash YYYY Age(Required)Phone(Required)Work PhoneEmail(Required) Address(Required) Street Address Address Line 2 City StateAlabamaAlaskaAmerican 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 Height(Required)Weight(Required) BMI Results for Adults Over 35: 19-26.9 Recommended 27-29.9 Overweight 30-39.9 Obese 40 (+) Morbidly Obese Waist Circumference(Required)Waist: Hip Ratio (waist/hip)(Required)Medical Status:Primary Physician(Required)Primary Physician Phone(Required)Secondary PhysicianSecondary Physician PhoneGeneral Health(Required) Excellent Good Fair Poor Medical & Social History: Please check the following that apply to you.(Required) High Blood Pressure Cardiovascular Disease Osteoporosis Tobacco Use Alcohol Use Insomnia Depression High Cholesterol Diabetes Mellitus Benign Prostatic Hyperplasia Asthma/COPD Erectile Dysfunction Malnutrition Cancer Other If you checked Cancer, please explain.If you checked Other, please explain.Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them:Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc): Other:Names of ALL Vitamins, Supplements, Non-prescription medicines, or other OTC products that you are currently using:Drug AllergiesFamily History: List Important DiseasesMotherMother Living / Deceased Living Deceased FatherFather Living / Deceased Living Deceased BrothersBrothers Living / Deceased Living Deceased SistersSisters Living / Deceased Living Deceased AuntsAunts Living / Deceased Living Deceased UnclesUncles Living / Deceased Living Deceased Paternal GrandmaPaternal Grandma Living / Deceased Living Deceased Paternal GrandpaPaternal Grandpa Living / Deceased Living Deceased Maternal GrandmaMaternal Grandma Living / Deceased Living Deceased Maternal GrandpaMaternal Grandpa Living / Deceased Living Deceased Do you feel more fatigued and/or tired than usual?(Required) N/A Mild Moderate Severe Have you noticed a decrease in your muscle mass?(Required) N/A Mild Moderate Severe Have you experienced a loss in muscle strength?(Required) N/A Mild Moderate Severe Have you experienced an increase in joint and/or muscle pains?(Required) N/A Mild Moderate Severe Have you noticed an increase in your waist size?(Required) N/A Mild Moderate Severe Do you have trouble losing weight?(Required) N/A Mild Moderate Severe Have you experienced a loss in height?(Required) N/A Mild Moderate Severe Do you have a decrease in your sex drive?(Required) N/A Mild Moderate Severe Have you experienced difficulty in establishing and/or maintaining full erections?(Required) N/A Mild Moderate Severe Have you experienced changes in your usual sleep pattern?(Required) N/A Mild Moderate Severe Do you feel a decrease in your mental sharpness?(Required) N/A Mild Moderate Severe Have you had trouble concentrating?(Required) N/A Mild Moderate Severe Do you experience less enjoyment in personal interests and hobbies?(Required) N/A Mild Moderate Severe I am ________ years old(Required)I feel ________ years old(Required)Please select 3 times that work best for a phone consultation with one of our pharmacists. Our times offered are Monday - Friday with time blocks from 9:00am-12:00pm, 12:00pm-3:00pm or 3:00pm-6:00pm. Consults typically last between 30 minutes and one hour. We will check availability and get back with you with a specific time.Date(Required) MM slash DD slash YYYY Time Block(Required)First Time Block Requested9:00am-12:00pm12:00pm-3:00pm3:00pm-6:00pmDate(Required) MM slash DD slash YYYY Time Block(Required)Second Time Block Requested9:00am-12:00pm12:00pm-3:00pm3:00pm-6:00pmDate(Required) MM slash DD slash YYYY Time Block(Required)Third Time Block Requested9:00am-12:00pm12:00pm-3:00pm3:00pm-6:00pmAttention Patients: Important Update! If you don't receive a "SUCCESS" message upon submission, please make sure all required fields have been completed and resubmit.
