Application

Have you received any treatment with us before?*
- Yes
- No
Name*
Last name*
Biological Sex*
Birth Date*
Age*
Phone 1*
Phone 2
Email*
Address
Zip Code
City
State*
Country*
Services*
Procedure*
Procedure*
Procedure*
Procedure*
Packages*
Packages*
In order to give you a quote we require the following pictures of you from the neck down with no clothes. You can cover your privates with a sticker
Front*
Drop files here or
Accepted file types: jpeg, jpg, gif, png.
Back*
Drop files here or
Accepted file types: jpeg, jpg, gif, png.
Left side*
Drop files here or
Accepted file types: jpeg, jpg, gif, png.
Right side*
Drop files here or
Accepted file types: jpeg, jpg, gif, png.
Emergency Contact
Name*
Phone*
* Required

Select your preferred measurement system*
- Metric ( kg - meters )
- Imperial ( lb - in )
Max weight (kg)*
Current weight (kg)*
Height (meters).*
BMI*
Max weight (lb)*
Current weight (lb)*
Height (ft)*
BMI*
Do you take any medications/drugs?*
- Yes
- No
List*
Name of Med Reason Dose Frecuency
Do you take, or have you taken in the past Blood-thinners?*
- Yes
- No
Explain the reason*
Do you have any allergies?
Penicillin*
- Yes
- No
Sulfa Drugs*
- Yes
- No
Iodine*
- Yes
- No
Tape*
- Yes
- No
Latex*
- Yes
- No
Aspirin*
- Yes
- No
Other

Have you had or do you have now?
Addictions*
- Yes
- No
Which one?*
High lipid levels*
- Yes
- No
Diagnostic date*
Treatment*
Arthritis*
- Yes
- No
Diagnostic date*
Treatment*
Cancer*
- Yes
- No
Diagnostic date*
Treatment*
Cholesterol and triglycerides*
- Yes
- No
Diagnostic date*
Treatment*
Stroke*
- Yes
- No
Diagnostic date*
Treatment*
Diabetes*
- Yes
- No
Diagnostic date*
Treatment*
Coronary Artery Disease*
- Yes
- No
Diagnostic date*
Treatment*
Liver disease*
- Yes
- No
Diagnostic date*
Treatment*
Lung Disease*
- Yes
- No
Diagnostic date*
Treatment*
Renal disease*
- Yes
- No
Diagnostic date*
Treatment*
Thyroid disease*
- Yes
- No
Diagnostic date*
Treatment*
Hypertension*
- Yes
- No
Diagnostic date*
Treatment*
Any other illnesses*
- Yes
- No
Other illnesses*
What other illness? * Diagnostic date* Treatment*
Gynecological History
Date of last menstrual period:*
Bleeding was*
- Normal
- Light
- Heavy
- Irregular
Have you been pregnant?*
- Yes
- No
How many times?
C-section
Do you use any type of birth control?*
- Yes
- No
Birth control
Type How long have you used this birth control?
Are you presently, or have you ever taken hormones?*
- Yes
- No
Hormones
Type How long have you been using hormone type?
Are you pregnant? or is there a possibility of you being pregnant?*
- Yes
- No

Have you had any previous surgery?*
- Yes
- No
Previous surgeries*
What surgery?* What was your age?* What year was it performed?* Any complications?*
Have you ever had bariatric surgery?*
- Yes
- No
Previous bariatric surgery*
Which one?* What was your age?* What year was it performed?* Any complications?*
Have you ever had a problem with an anesthetic?*
- Yes
- No
Describe the problems*
Have you ever had bariatric surgery?*
- Yes
- No
Bariatric surgeries*
Type of surgery* Year performed*
Have you ever had plastic surgery?*
- Yes
- No
Plastic Surgeries*
Type of surgery* Year performed*
Have you ever had a prostate surgery?*
- Yes
- No
Prostate surgeries*
Type of surgery* Year performed*
Have you ever had pelvic surgery?*
- Yes
- No
Pelvic Surgeries*
Type of surgery* Year performed*
How long ago was this surgery (vasectomy)?
Specify the year*
Where was it done?*
Did you have any complications (vasectomy)?*
- Yes
- No
Specify*
Do you have any discomfort or pain in your testicles?*
- Yes
- No
When did you realize the discomfort?*
Has any testicular operation been performed other than vasectomy?*
- Yes
- No
Testicular operations*
Year* Any complications?*

Currently...
Do you smoke cigarettes?*
- Yes
- No
Amount
Number of years
Have you quit smoking?*
- Yes
- No
How long?
Do you drink alcohol?*
- Yes
- No
Amount?*
Use recreational drugs?*
- Yes
- No
Amount?*
Have you ever used intravenous drugs (or skin-popping)?*
- Yes
- No
Are you easily fatigued?*
- Yes
- No
Do you have shortness of breath?*
- Yes
- No
Do you have asthma?*
- Yes
- No
Do you use a B-PAP or C-PAP while you sleep?*
- Yes
- No
Do you exercise?*
- Yes
- No
Exercise*
Type How long? How frecuent? Hours per day
Hours you sleep at night*
Do you take sleeping pills?*
- Yes
- No
Do you suffer from anxiety / depression?*
- Yes
- No
Do you take pills for anxiety / depression?*
- Yes
- No
Do you feel under stress?*
- Yes
- No
Do you have erections in the morning?*
- Yes
- No
How many per week?
Do you have problems getting erections?*
- Yes
- No
Since when?
Describe your problem
Do you have problems maintaining an erection?*
- Yes
- No
Do you take Viagra?*
- Yes
- No
When did you began?*
How did the pills work?*
How often?*
How do you take them?*
Do you take any natural remedy for Erectile dysfunction?*
- Yes
- No
What kind?*
How did it work?*
Where did you get them?*
Has medication been injected for dysfunction erectile?*
- Yes
- No
How many times?*
How did it work?*
Have you had an erection longer than 6 hours?*
- Yes
- No
When?*
How was it resolved?*
Did you get medical attention?*
Do you suffer from penile curvature?*
- Yes
- No
How intense?*
Which direction?*
Does it hurt?*
Does it prevent intercourse?*
Has PRP been injected for erectile dysfunction?*
- Yes
- No
Have you received stem cell treatment for erectile dysfunction?*
- Yes
- No
Have you received vascular regeneration therapy with low intensity wave therapy for erectile dysfunction?*
- Yes
- No
Has there been prostate cancer in your family?*
- Yes
- No
Has the PSA test ever been done?*
- Yes
- No
When?*
What was the result?*
Have you ever had a prostate biopsy?*
- Yes
- No
When?*
Where?*
What was the result?*
Do you get up at night to urinate?*
- Yes
- No
How many times?*
Drips / spills after urinating?*
- Yes
- No
Do you urinate frequently? (Every 2 hours or less)*
- Yes
- No
Does it take a long time for urine to come out?*
- Yes
- No
When urinating ...
Does the urine stream pause frequently?*
- Yes
- No
Is the urine stream very thin?*
- Yes
- No
Is the urine stream weak?*
- Yes
- No
Do you have to push?*
- Yes
- No
Have you ever bled?*
- Yes
- No
Have you had to use a urinary catheter?*
- Yes
- No
For how long?*
Have you ever had a urinary infection?*
- Yes
- No
What antibiotic(s) did you take?*
Do you suffer from urinary incontinence?*
- Yes
- No
Since when?*
Do you take medications for prostate obstruction or BPH (Benign Prostate Hypertrophy)?*
- Yes
- No
Type*
Since when?*
Do you take Viagra or any medication for erectile dysfunction?*
- Yes
- No
Since when?*
Has it worked?*
How often?*
How do you take it?*

What surgery?*	What was your age?*	What year was it performed?*	Any complications?*

Name of Med	Reason	Dose	Frecuency

What other illness? *	Diagnostic date*	Treatment*

Type	How long have you used this birth control?

Type	How long have you been using hormone type?

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