HEALTH HISTORY QUESTIONNAIRE

For starters, congratulations—we’re excited to see you’ve taken an interest in creating a better living for yourself through science.

I know you are just as excited as we are to get started however Marek is only able to take on a limited amount of patients per year. Please complete this health history questionnaire to make sure you qualify to join. If you are successful you will be redirected to our booking system to schedule your intake evaluation.

Demographics

Patient Information

Must enter date as YYYY-MM-DD

Personal Health History

Do you have issues with Anxiety, Sleep, or Sexual Performance?
Do you suffer from any of the following conditions? (select all that apply)
Are you experiancing difficulty completing urination?
Have you recently noticed any lumps, swelling, tenderness or pain in your testicles?
Do you suffer from any of the following conditions? (select all that apply)
Do you suffer from heavy, irregular or painful periods?
Are you currently pregnant or breastfeeding?
Do you suffer from frequent bladder or kidney infections?
Have you recently note any breast lumps, tenderness, pain or nipple discharge?

Health Habits

Illegal drug use?

Goals

What are you interested in?
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Thanks for your submission

We are generating your intake paperwork for signature below.

After Signing the Document

Book Intake Meeting

We're sorry, but right now we can only service US Residents.

Signup below for more information as we expand outside of the United States.

What areas interest you?
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We’re sorry, you must be 18+ years of age to use our services.