Medical Intake | Man vs Health Medical Optimization

Personal Information

Let's start with your basic details

Full Legal Name *

Preferred Name (if different)

Date of Birth *

Gender *

Male Female Non-binary Prefer not to answer

Home Address *

City *

State *

ZIP Code *

Phone Number *

Email Address *

Emergency Contact & Location

For your safety and our compliance

Emergency Contact Name *

Emergency Contact Phone *

Relationship *

Which state do you currently reside in? *

Florida North Carolina Other (we currently only serve FL and NC)

I confirm that I will be physically located in Florida or North Carolina during all telehealth appointments.

Reason for Visit

Help us understand your health goals

What service are you scheduling? *

Initial Medical Optimization Consultation Follow-up consultation Annual Medical Concierge enrollment Other

What are your primary health goals? (Check all that apply) *

Weight loss Testosterone optimization / TRT Erectile dysfunction treatment Hair loss treatment Energy and vitality improvement Preventive health optimization Metabolic health improvement Other (please specify below)

Chief Complaint: What is the main issue or concern you'd like to address? *

How long have you been experiencing this issue?

Current Health Status

Your current health snapshot

How would you rate your overall health? *

Excellent Very Good Good Fair Poor

Current Weight (lbs) *

Height *

On a scale of 1-10, how is your energy level throughout the day? *

1 - Exhausted 5 10 - High energy

On a scale of 1-10, how well do you sleep? *

1 - Terrible 5 10 - Excellent

Average hours of sleep per night *

Less than 5 hours 5-6 hours 6-7 hours 7-8 hours More than 8 hours

Medical History

Your past and current conditions

If you checked Cancer, Autoimmune, or other conditions, please provide details:

Have you ever been hospitalized? If yes, please explain when and why.

Have you ever had surgery? If yes, please list surgeries and approximate dates.

Do you have any history of blood clots (DVT, pulmonary embolism)? *

Yes No Unsure

Do you have sleep apnea? *

Yes, diagnosed and treated (CPAP) Yes, diagnosed but not treated Suspected but not diagnosed No

Family History

Immediate family members (parents, siblings)

If you checked cancer or other significant conditions, please provide details:

Medications & Allergies

Current medications and known allergies

Are you currently taking any prescription medications? *

Yes No

Are you currently taking any over-the-counter medications regularly? *

Yes No

Are you currently taking any vitamins, supplements, or herbal products? *

Yes No

CRITICAL QUESTION:

Do you currently take or have you ever taken nitrates for chest pain? (Examples: nitroglycerin, isosorbide) *

Yes No Unsure

Do you have any medication allergies? *

Yes No Unknown

Do you have any food allergies?

Yes No

Any other allergies (environmental, latex, etc.)?

Lifestyle & Social History

Your daily habits and lifestyle

Occupation / Career *

Marital Status *

Do you currently smoke tobacco? *

Never smoked Former smoker Current smoker Vape/E-cigarette user

Do you use alcohol? *

No, I don't drink Occasionally (1-2 drinks/week) Moderately (3-7 drinks/week) Heavily (8+ drinks/week)

Do you use recreational drugs? *

No Yes (marijuana) Yes (other substances)

How often do you exercise? *

Never / Sedentary 1-2 times per week 3-4 times per week 5+ times per week

What type of exercise do you do? (Check all that apply)

Walking Running/Jogging Weight training Cycling Swimming Sports Yoga/Pilates HIIT

How would you describe your typical diet? *

On a scale of 1-10, what is your current stress level? *

1 - Very low 5 10 - Extremely high

What are your main sources of stress?

Sexual Health

For TRT and ED treatment planning

Are you experiencing any of the following? (Check all that apply)

Low libido (decreased sex drive) Difficulty achieving erections Difficulty maintaining erections Decreased sexual satisfaction None of the above Prefer not to answer

Have you used ED medications before (Viagra, Cialis, Levitra)? *

Yes, they worked well Yes, but didn't work or caused side effects No, never tried Prefer not to answer

Do you have any plans to father children in the next 2-3 years? *

Yes, planning to have children No, not planning children Uncertain Already have vasectomy or infertile

Have you ever been diagnosed with or treated for low testosterone?

Yes, currently on TRT Yes, previously treated but stopped No, never diagnosed Unsure

Have you had prostate issues? (Check all that apply)

BPH (enlarged prostate) Prostatitis Elevated PSA Prostate cancer None Unknown

Mental Health Screening

Your emotional well-being

Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless? *

Not at all Several days More than half the days Nearly every day

Over the past 2 weeks, how often have you been bothered by little interest or pleasure in doing things? *

Not at all Several days More than half the days Nearly every day

Over the past 2 weeks, how often have you been bothered by feeling nervous, anxious, or on edge? *

Not at all Several days More than half the days Nearly every day

Are you currently being treated for depression, anxiety, or other mental health conditions?

Yes No

Have you ever had thoughts of harming yourself or others? *

No Yes, in the past Yes, recently

Review of Systems

Symptoms in the past 3 months

General symptoms (check all that apply) *

Fatigue Weakness Fever or chills Unintentional weight loss Unintentional weight gain Night sweats None

Cardiovascular symptoms

Chest pain Palpitations (racing heart) Shortness of breath Swelling in legs or feet Leg pain with walking None

Gastrointestinal symptoms

Nausea or vomiting Abdominal pain Diarrhea Constipation Heartburn or reflux None

Genitourinary symptoms

Frequent urination Difficulty urinating / weak stream Getting up at night to urinate Testicular pain or lumps None

Neurological symptoms

Headaches Dizziness Numbness or tingling Memory problems Difficulty concentrating None

Previous Labs & Providers

Your medical care team

Have you had lab work done in the past 12 months?

Yes No Unsure

Have you had any of these tests? (Check if known)

Testosterone level Complete Blood Count (CBC) Comprehensive Metabolic Panel Lipid Panel (Cholesterol) Hemoglobin A1c PSA (Prostate marker) Thyroid (TSH, T3, T4) Vitamin D None / Unsure

Do you currently have a primary care physician? *

Yes No

When was your last physical exam?

Are you currently seeing any specialists?

Yes No

Goals & Expectations

What you want to achieve

What are your top 3 health goals for the next 6-12 months? *

What does success look like to you? *

What obstacles or challenges do you anticipate in achieving your goals?

On a scale of 1-10, how motivated are you to make changes to improve your health? *

1 - Not motivated 5 10 - Extremely

Are you willing to commit to lifestyle changes (diet, exercise, stress management) in addition to medical treatment? *

Yes, absolutely Yes, but it's difficult for me Unsure No, I prefer medication-only approach

How did you hear about Man vs Health? *

Is there anything else you'd like your provider to know before your consultation?

Service Agreement & Consent

Please review and acknowledge

MAN VS HEALTH MEDICAL OPTIMIZATION
MEDICAL SERVICES AGREEMENT

1. SERVICES OVERVIEW

Man vs Health Medical Optimization provides telehealth medical services focused on men's health optimization. All services are delivered by licensed healthcare providers (physicians, nurse practitioners, or physician assistants) practicing within their scope of licensure.

2. THIS IS MEDICAL CARE

By entering into this Agreement, a formal provider-patient relationship is established. This IS medical care provided by licensed healthcare professionals, including medical diagnosis, treatment, and prescription of medications.

3. TELEHEALTH CONSENT

What is Telehealth: Telehealth involves the use of electronic communications (video conferencing) to provide medical care at a distance.

Benefits: Convenient access to care from home, reduced travel, easier scheduling, access to specialized care.

Limitations: Provider cannot perform physical examination. Some conditions require in-person evaluation. Technology failures may disrupt care.

Privacy: While we use HIPAA-compliant platforms, no electronic communication is 100% secure. You should ensure privacy on your end.

4. STATE RESTRICTIONS

Provider ONLY provides services to patients physically located in Florida or North Carolina. You must be physically present in one of these states at the time of EVERY telehealth visit.

5. EMERGENCY DISCLAIMER

CRITICAL: This telehealth service is NOT for medical emergencies. If you experience chest pain, difficulty breathing, stroke symptoms, severe injury, or suicidal thoughts, call 911 immediately or go to the nearest emergency room. Provider is NOT available 24/7 for emergencies.

6. PAYMENT TERMS

Man vs Health Medical Optimization operates on a DIRECT PAY (cash pay) model. We do NOT accept insurance, Medicare, or Medicaid. You are separately responsible for laboratory testing fees (paid to LabCorp) and medication costs (paid to pharmacy).

7. REFUND POLICY

Full refund if cancelled 48+ hours before appointment. No refund if cancelled less than 48 hours before appointment or no-show. 30-day satisfaction guarantee for packages and annual concierge services.

8. PATIENT RESPONSIBILITIES

You agree to: provide accurate information, follow treatment plans, use medications safely, communicate appropriately, attend appointments, and maintain relationship with primary care physician.

9. INFORMED CONSENT REQUIREMENTS

Separate informed consent forms are REQUIRED before initiating specific treatments including TRT, GLP-1 medications, ED treatments, and hair loss treatments.

10. CONTROLLED SUBSTANCES

If prescribed controlled substances (such as testosterone), you must sign a separate Controlled Substance Agreement and comply with all monitoring requirements.

11. HIPAA AND PRIVACY

Man vs Health Medical Optimization is a HIPAA-covered entity. Your Protected Health Information (PHI) will be handled in accordance with HIPAA regulations. Telehealth visits may be recorded for documentation purposes and stored on HIPAA-compliant servers.

12. DISPUTE RESOLUTION

Any disputes arising from this Agreement shall be resolved by binding arbitration in accordance with the rules of the American Arbitration Association. This Agreement is governed by the laws of the State of Florida or North Carolina (depending on your residence).

13. LIMITATION OF LIABILITY

Medicine is not an exact science. No guarantees can be made regarding treatment outcomes. Individual responses to treatment vary. Provider is not liable for actions of third parties (pharmacies, labs, etc.).

Required Acknowledgments

Please check each box to confirm your understanding:

I have read and understand this Medical Services Agreement

I understand this IS medical treatment provided by licensed healthcare professionals

I consent to receiving medical care via telehealth and understand its limitations

I confirm I will be physically located in Florida or North Carolina during all appointments

I understand this is NOT for emergencies and I will call 911 for emergencies

I understand the direct pay model and am responsible for all fees, labs, and medications

I consent to recording of visits and handling of my health information per HIPAA

I agree to binding arbitration for any disputes

I have completed this intake form truthfully and to the best of my knowledge

Digital Signature

Type your full legal name to sign electronically *

Date:

Patient Intake Form

Personal Information

Emergency Contact & Location

Reason for Visit

Current Health Status

Medical History

Family History

Medications & Allergies

Lifestyle & Social History

Sexual Health

Mental Health Screening

Review of Systems

Previous Labs & Providers

Goals & Expectations

Service Agreement & Consent

MAN VS HEALTH MEDICAL OPTIMIZATIONMEDICAL SERVICES AGREEMENT

1. SERVICES OVERVIEW

2. THIS IS MEDICAL CARE

3. TELEHEALTH CONSENT

4. STATE RESTRICTIONS

5. EMERGENCY DISCLAIMER

6. PAYMENT TERMS

7. REFUND POLICY

8. PATIENT RESPONSIBILITIES

9. INFORMED CONSENT REQUIREMENTS

10. CONTROLLED SUBSTANCES

11. HIPAA AND PRIVACY

12. DISPUTE RESOLUTION

13. LIMITATION OF LIABILITY

Required Acknowledgments

Digital Signature

Intake Complete!

Next Steps

MAN VS HEALTH MEDICAL OPTIMIZATION
MEDICAL SERVICES AGREEMENT