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Form – for category only
Welcome to Human Performance Health Clinic!
Health Screening Assessment
What category of treatment are you looking for?
Please select a treatment type
Hormone Therapy
Testosterone Therapy
Peptide Therapy
Weight Loss Management
Pathology Evaluation
Erectile Dysfunction
Chronic Pain Treatment
Sleep Quality Management
Hair Loss Treatment
Medical Cannabis (THC & CBD)
Testosterone Therapy
What is the desired goal of the treatment you are looking for?
Do you have any health issues?
Do you have any allergies?
Do you smoke?
Yes
No
If so, how regularly?
Do you drink alcohol?
Yes
No
If so, how regularly?
Do you take any medications or hormone therapy?
Do you have any Injuries?
Is there anything else you would like to tell us prior to discussing with the team?
First Name
Last Name
Phone
Email
I consent to receive the PDF and additional research via email, phone, SMS, or other electronic means from Human Performance Health Clinic. By checking this box, I acknowledge that I have reviewed and accepted the Terms & Conditions and Privacy Policy of Human Performance Health Clinic. I also agree to be reached out to concerning the results of the quiz and for other informational and promotional purposes.
Submit Assessment
