Intake Form – EdgeRX Men's Health

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Name(Required)

First Last

Email(Required)

Phone (WhatsApp enabled)(Required)

Date of Birth(Required)

Month

Day

Year

Weight (kg)

Hight (cm)

Do you have any of the following? (Select all that apply)(Required)

High Blood Pressure

Diabetes

Heart Disease

High Cholesterol

Depression/Anxiety

None of the above

Any surgeries or hospitalizations in the past 5 years?(Required)

Yes

If "Yes" selected, please specify

Any allergies or anaphylaxis to products, treatments or medication(Required)

Yes

If "Yes" selected, please specify

Do you take any medication or supplements?(Required)

Yes

List your medications

Do you drink?(Required)

Never

Occasionally

Often

Do you smoke?(Required)

Yes

Occasionally

Do you take nitrates (e.g. nitroglycerin) or chest pain meds?(Required)

Yes

Do you ever experience any of the following? (Check all that apply)(Required)

Chest Pain

Shortness of Breath

Irregular Heartbeat

Priapism (erection lasting more than 4h)

None of the above

Have you ever suffered from any of the following? (Check all that apply)(Required)

Heart Attack

Stroke

Thyroid Problems

Vision/Hearing Loss

Auto-Immune Disease (e.g. lupus, scleroderma, rheumatoid arthritis)

Hepatitis

Asthma

Osteoporosis

Prophyria

Epilepsy

Cancer

Clotting Abnormalities

Uncontrolled High or Low Blood Pressure

Kidney Disease

Stomach Ulcer or Colitis (Inflammation of the colon)

None of the above

Consent(Required)

I hereby agree to the following: 1.1 I acknowledge that the staff of EdgeRX are not liable for any guarantees, warranties, or assurances regarding the results obtained. 1.2 I certify that I am a competent adult aged 18 or older, and this decision is made freely and voluntarily. 1.3 I have answered all questions herein with accuracy, honesty, and to the best of my ability. Should there be any changes to my medical history, operations, or medications, I will inform EdgeRX of these updates and any other serious conditions that may be relevant. 1.4 I agree to adhere to all safety precautions and regulations during the treatments and to follow all provided instructions. 1.5 EdgeRX is not responsible for treatments conducted by other practitioners or centers that may cause side effects to the therapy. 1.6 My digital submission of this form signifies my informed consent to the therapy and my acceptance of the conditions outlined herein. I have read and understood the treatment information guide related to my therapy. I have been advised that all treatments may differ due to variables such as age, lifestyle etc.

Contact

I agree to be contacted on WhatsAp

EdgeRX Intake Form