Patient Intake - Oak Longevity Institute

Progress

Step 1 of 10

Welcome to Oak Longevity Institute

Let’s get to know you. We’ll start with basic information.

First Name *

Last Name *

Date of Birth *

Email Address *

Phone Number *

State of Residence *

Sex Assigned at Birth *

Male

Female

Preferred Pronouns

Step 2 of 10

What brings you in today?

Select all treatment areas that interest you. (Select at least one)

Peptide Therapy (BPC-157, TB-500, Sermorelin)

Weight Management (Semaglutide)

Hormone Optimization (Testosterone, DHEA, Pregnenolone)

Sexual Health (Tadalafil, PT-141)

Longevity Protocols (NAD+, Metformin, Rapamycin)

Hair Restoration (Finasteride, Minoxidil, Dutasteride)

Step 3 of 10

Current Medications

List all prescription and over-the-counter medications you’re currently taking.

Medication Name

Dose

Frequency

Step 3 of 10 (continued)

Allergies

Include medication, food, and environmental allergies with severity level.

Allergen

Type

Severity

Reaction Description

Step 3 of 10 (continued)

Medical Conditions

Select all conditions that apply to you.

Hypertension

Diabetes

Heart Disease

Thyroid Disorder

Liver Disease

Kidney Disease

Depression

Anxiety

History of Cancer

COPD

Other Conditions (free text)

Step 3 of 10 (continued)

Past Surgeries & Family History

Help us understand your surgical and family medical history.

Past Surgeries

Procedure Name

Year

Family Medical History

Check any conditions that run in your family

Heart Disease

Cancer

Diabetes

Stroke

Alzheimer’s

Mental Illness

Current Supplements & Vitamins

Step 4 of 10

Weight Management Assessment

Additional information for weight loss optimization

Current Weight (lbs) *

Goal Weight (lbs) *

Height (inches) *

Previous GLP-1 Receptor Agonist Experience

No prior experience

Semaglutide (Ozempic/Wegovy)

Other GLP-1 therapy

Previous Weight Loss Attempts

GI History (nausea, GERD, IBS, etc.)

Step 4 of 10

Hormone Optimization Assessment

Symptoms and hormone therapy history

Symptoms You’re Experiencing (select all that apply)

Fatigue

Low Libido

Brain Fog

Muscle Loss

Mood Changes

Hot Flashes

Previous Hormone Therapy Experience

Previous Hormone Lab Results (if known)

Step 4 of 10

Peptide Therapy Goals

What are you hoping to achieve?

Primary Goals (select all that apply)

Recovery/Performance

Injury Healing

Anti-Aging

Muscle Growth

Cognition

Immune Health

Current or Recent Injuries

Current or Previous Peptide Experience

Step 4 of 10

Sexual Health Assessment

Confidential information for optimal treatment

Erectile Dysfunction Severity (if applicable)

No erectile dysfunction

Mild (occasional difficulty)

Moderate (frequent difficulty)

Severe (persistent)

Onset & Duration

Cardiovascular Risk Assessment

Have you experienced any of these?

Previous Heart Attack (MI)

Previous Stroke

Chest Pain/Angina

Heart Arrhythmia

Current Nitrate Medication Use

Not taking any nitrates

Currently taking nitrates

Step 4 of 10

Longevity Optimization Goals

What aspects of health are you most interested in optimizing?

Health Optimization Goals

Known Biomarkers (if available)

Current Longevity Stack

Step 4 of 10

Hair Loss Assessment

Understanding your hair restoration goals

Hair Loss Pattern (Norwood Scale)

Stage 1-2 (Minimal recession)

Stage 3-4 (Moderate recession)

Stage 5-7 (Advanced/extensive)

Onset of Hair Loss

Family History of Hair Loss

No family history

Father/Paternal side

Mother/Maternal side

Previous Hair Loss Treatments

Step 5 of 10

Vital Signs & Lifestyle

Help us understand your overall health profile.

Height (inches) – if not entered yet *

Current Weight (lbs) – if not entered yet *

Blood Pressure (Systolic) – if known

Blood Pressure (Diastolic) – if known

Resting Heart Rate (bpm) – if known

Exercise Frequency & Type

Average Sleep per Night (hours)

Sleep Issues (if any)

Stress Level (1-10 scale)

5/10

Alcohol Use

Tobacco/Nicotine Use

Never used

Former user

Current user

If current/former, provide details

Recreational Drug Use

Diet Description

Step 6 of 10 – SAFETY SCREENING

Safety & Contraindications

Critical health information. Honest answers ensure your safety.

Are you currently pregnant or breastfeeding?

Yes

N/A

Do you have active cancer or history of cancer?

History of cancer (in remission)

Active cancer diagnosis

Note: Will discuss individually to ensure treatments are appropriate.

Blood Clotting Disorders or Bleeding Issues?

Yes (DVT, PE, hemophilia, etc.)

Liver or Kidney Disease?

Yes

Cardiovascular Event in Past 6 Months?

Heart attack, stroke, unstable angina, or major cardiac procedure

Yes

Currently Taking Nitrate Medications?

Contraindication for certain treatments

Yes

Any Suicidal Ideation or Mental Health Crisis?

Yes – Please contact crisis support

If yes, please call 988 (Suicide & Crisis Lifeline)

Step 7 of 10

Labs & Medical Records

Provide any recent test results or medical information.

Recent Bloodwork (Optional file upload)

PDF, JPG, or PNG format. our expert physician can review for optimization.

Date of Last Blood Draw

Primary Care Physician Name (Optional)

Primary Care Contact (Optional)

Preferred Pharmacy

Step 8 of 10

Health Goals & Expectations

What do you want to achieve through this program?

Primary Health Goal

Timeline Expectations

1-3 months

3-6 months

6-12 months

Ongoing/Long-term

Preferred Communication Method

Phone

SMS

Patient Portal

How Did You Hear About Us?

Any Other Information We Should Know?

Step 9 of 10

Consent & Legal Agreements

Please acknowledge these important agreements.

I understand and consent to telehealth services. I acknowledge the limitations of video consultation and understand that in-person examination is not being conducted.

I acknowledge receipt of Oak Longevity Institute’s HIPAA Privacy Notice and understand my health information will be protected according to federal law.

I consent to receiving prescribed medications and understand the risks, benefits, and alternatives. I will report any adverse reactions immediately.

I acknowledge the No Surprises Act and understand how surprise bills may or may not apply to my care.

I agree to the membership terms and understand the costs associated with consultations and medication.

E-Signature (Type Your Full Name) *

By typing your name, you electronically sign this document.

Date *

Your Health Summary

Review your information below. our expert physician will use this to create your treatment plan.