Male Intake Form

Your Name*

First Last

Date*

Your Phone Number*

Date of birth*

Your Email*

Which of our locations is best for you?*

63 E 800 N, Spanish Fork, Utah
3435 Pony Express Pkwy Suite 120, Eagle Mountain, Utah

1) Decline in your feeling of general well-being (general state of health, subjective feeling)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

2) Joint pain & muscular ache (lower back pain, joint pain, pain in a limb, general back ache)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

3) Excessive sweating (unexpected/sudden episodes of sweating, hot flashes independent of strain)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

4) Sleep problems (difficulty in falling asleep, difficulty in sleepiing through, waking up early and feeling tired, poor sleep, sleeplessness)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

5) Increased need for sleep, often feeling tired*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

6) Irritability (feeling aggressive, easily upset about little things, moody)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

7) Nervousness (inner tension, restlessness, feeling fidgety)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

8) Anxiety (feeling panicky)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

9) Physical exhaustion / lacking vitality (general decrease in performance, reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, of having to force oneself to undertake activities)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

10) Decrease in muscular strength (feeling of weakness)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

11) Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

12) Feeling that you have passed your peak*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

13) Feeling burnt out, having hit rock-bottom*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

14) Decrease in beard growth*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

15) Decrease in ability/frequency to perform sexually*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

16) Decrease in the number of morning erections*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

17) Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

Please share any addition comments about your symptoms you would like to address.

Do you have cold hands or feet?*

Yes
No

Do you have gas, bloating, or abdominal pain after eating?*

Yes
No

Please select your WEEKLY activity level based on this criteria --> Physical activity that accelerates heart rate / breathlessness*

0-1 Day Per Week (Low)
2-3 Days Per Week (Average)
3+ Days Per Week (High)

Recent PSA:*

Yes
No
Not Sure

Recent digital rectal exam:*

Normal
Abnormal
Not Sure

Please list any prior hormone therapy?

History of Prostate problems or Biopsy? If so, please provide details.

This informative evening is dedicated to unraveling the complexities of hormones and their vital role in our health and well-being. Theresa Warren, a knowledgeable Family Nurse Practitioner with a focus on hormonal health, along with industry expert Tauscha Johnson, will guide you through the basics of hormone function, common hormonal imbalances, and practical strategies for maintaining hormonal harmony. Whether you're curious about how hormones affect your mood, energy levels, or overall health, this event promises to provide valuable insights and actionable advice. Don't miss this opportunity to empower yourself with knowledge and take control of your hormonal health!
Our nurses will be available that evening to provide blood draws for anyone who wishes to check their hormone levels before consulting with our Medical Director.
*Financing options available.

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About Summit Medical Spa

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Location

63 East 800 North
Spanish Fork, UT 84660

3436 Pony Express Parkway, Suite 120
Eagle Mountain, UT 84005

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