GENERAL PATIENT FORM Section A: Patient InformationName(Required) First Last Identity / Passport NumberDate of Birth(Required) YYYY slash MM slash DD AgeGender(Required) Female Male Address Street Address Address Line 2 City Province Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone (Cell)Phone (Home / Work)Email(Required) Occupation Next of Kin / Emergency ContactName Relationship Contact Number Your regular doctor / primary care provider (PCP or GP)Name Practice / Contact Number Do you consent to Premier Body communicating with your PCP / GP where clinically necessary?(Required) Yes No Section B: Programme(s) of interestPlease indicate the programme(s) you are interested in (the PB Doctor will confirm suitability) Hormone therapy / TRT (men) Hormone therapy (women) Medical weight management Insulin resistance Diabetes Pre-diabetes Supplements Peptide therapy IV drips (vitamin) IV drips (peptide-infused) Wellness Not sure / advise me Section C: Presenting concerns and goalsPlease check any of the following that currently apply to you: Fatigue / low energy Low or depressed mood Weight gain / weight issues Stress Irritability / moodiness Poor sleep / insomnia Low immunity Migraines / headaches Low libido / sexual health Hot flushes / night sweats Muscle loss / poor recovery Brain fog / poor focus Digestive issues / IBS Muscle spasms / cramps Numbness / tingling Anaemia PMS Trying to conceive / fertility Insulin resistance / metabolic Anti-ageing / longevity Please describe your main goal(s) for engaging Premier BodySection D: Medical history disclosurePlease check the box for any condition you have now or have had in the past High blood pressure / hypertension Low blood pressure Arrhythmia / abnormal heart rhythm Abnormal EKG / ECG Angina Heart attack (MI) Congestive heart failure Heart disease (other) Blood clots / DVT / pulmonary embolism Stroke / TIA Bleeding disorder Abnormal / undiagnosed bleeding Anaemia G6PD deficiency Polycythaemia / high red cell count Diabetes Thyroid disease (over- or under-active) Thyroid cancer / medullary thyroid carcinoma Multiple Endocrine Neoplasia (MEN2) Pancreatitis Gallbladder disease Liver disease Kidney disease Autoimmune disease Cancer (any – specify type below) Hormone-sensitive cancer (breast / prostate / ovarian / uterine) Prostate disease / enlargement Epilepsy / seizures Depression / anxiety / mental health Eating disorder (current or past) Asthma Ocular (eye) degeneration Oedema / ankle swelling Sudden unexplained weight loss Current illness / infection Fainting with needles / blood Pregnant / breastfeeding (see Section I) Migraine with aura Please list all current and past medical conditions, diagnoses, hospitalisations and surgeries (with dates)Any abnormal results from your last blood test? No Yes If yes, please give detailsList any medical devices implanted in your body (e.g. pins, plates, pacemaker, stents):Section E: Medication disclosurePlease disclose your medication history (include dosages where known):Prescription medication (current and recent)Supplements / vitamins (current and recent)Hormonal medication / HRT / contraceptionRecreational drugs (current and recent)Recent vaccinationsSection F: Allergies and sensitivitiesAre you allergic or sensitive to any of the following? (state what, if yes)Medications (specify)Vitamins / minerals (specify)Latex (gloves / dressings)Foods or other (specify)Please fully disclose all known or suspected allergies, and the reaction experiencedSection G: Family historyPlease check any condition present in a close blood relative (parent, sibling, child) Heart disease / heart attack Stroke Blood clots / DVT / PE High blood pressure Diabetes Thyroid disease Medullary thyroid carcinoma / MEN2 Cancer (specify type below) Hormone-sensitive cancer (breast / prostate) Autoimmune disease Detail (relationship and condition)Section H: LifestyleDo you smoke or vape? No Yes If yes, how much per day?Do you drink alcohol? No Yes If yes, how many units per week?Do you use recreational substances? No Yes (Specify in Section E) Exercise (type and frequency per week)Typical diet / eating patternAverage sleep per nightCurrent stress level (low / moderate / high)Caffeine intake per daySection I: Women's healthAre you currently pregnant? Yes No Are you trying to become pregnant? Yes No Are you breastfeeding? Yes No Are you currently using hormonal contraception or HRT? Yes (Specify in Section E) No Any personal history of hormone-sensitive cancer (breast / ovarian / uterine)? Yes No Menstrual status (regular / irregular / perimenopausal / postmenopausal)Date of last menstrual periodDate of last mammogram / gynaecological checkSection J: Men's health / TRT screeningDo you have any urinary or prostate symptoms (weak stream, frequency, difficulty)? Yes No Do you wish to preserve fertility? Yes No (testosterone therapy may reduce fertility) Any personal history of prostate or breast cancer? Yes No Have you been diagnosed with sleep apnoea? Yes No Any history of raised haematocrit / red blood cell count? Yes No Date and result of last PSA test (if known)Section K: Weight and metabolic screening (complete if applicable)Current weight (kg)Height (cm):Goal weight (kg):Highest / lowest adult weightHave you used weight-loss medication before? Yes (specify in Section E) No Personal or family history of medullary thyroid carcinoma or MEN2? Yes (contra-indicates GLP-1 therapy) No Any history of pancreatitis? Yes No Any history of gallbladder disease or gallstones? Yes No Any current or past eating disorder? Yes No Section M: Declaration and consentConsent(Required) I confirm the followingI confirm that the information I have given in this questionnaire is true, accurate and complete to the best of my knowledge. I understand that the PB Doctor will rely on it in deciding whether and how to treat me, and that withholding or misstating information may increase the risk of harm to me. I undertake to inform Premier Body promptly of any change to my health, medication or the information above. This questionnaire forms part of the Agreement between me and Premier Body, together with the Online Intake Form, the Medical Services Agreement and any applicable consent forms. My information is processed in accordance with the Privacy Notice and the data-processing terms of that Agreement. Date MM slash DD slash YYYY Name(Required) First Last Section L: SECTION L: For office use – baseline measurementsHeightBMIWeightBlood PressureHeart RateWaistReviewed by (PB Doctor / staff)Date MM slash DD slash YYYY
