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NU MD — New Patient Questionnaire

NU MD — New Patient Origination Questionnaire

Name(Required)
DD slash MM slash YYYY
GENERAL HEALTH OVERVIEW
What brings you to NU MD today?(Required)
(Check all that apply)
Current Symptoms or Concerns(Required)
HEALTH HISTORY(Required)
Have you ever been diagnosed with any of the following?
Current Medications
Please list all current prescription medications, supplements, peptides, or hormone therapies:
Allergies
List allergies and reactions:
LIFESTYLE & WELLNESS
Exercise Frequency(Required)
Tobacco Use(Required)
Alcohol Consumption(Required)
Sleep Quality(Required)
HORMONE / TRT SECTION (OPTIONAL)
Have you previously used TRT or hormone therapy?(Required)
If yes, please explain:
Symptoms You May Be Experiencing(Required)
If yes, please explain:
WEIGHT LOSS SECTION (OPTIONAL)
Have you previously used GLP-1 medications?(Required)
If yes, which medications?
CONSENT & SIGNATURE
I certify that the information provided is accurate and complete to the best of my knowledge.
DD slash MM slash YYYY
TELEMEDICINE ACKNOWLEDGEMENT(Required)
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