PT Health Screening - Regenics

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Order ID

Do you have a history of high blood pressure, heart disease, stroke, or other cardiovascular conditions?(Required)

No

Yes

Have you experienced chest pain, irregular heartbeats, or fainting in the past six months?(Required)

No

Yes

Do you have any known kidney or liver disease?(Required)

No

Yes

Have you been diagnosed with diabetes, insulin resistance, or obesity?(Required)

No

Yes

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Are you currently taking blood pressure medications, nitrates, PDE-5 inhibitors (like Viagra or Cialis), antidepressants, antipsychotics, or dopamine-related medications?(Required)

No

Yes

Are you currently taking any of the below medications?(Required)

Blood pressure medications

Nitrates

Viagra / Cialis

Antidepressants

Antipsychotics

Dopamine-related medications

None of the above

Which medication(s) are you currently taking(Required)

Is your condition currently well-managed?(Required)

Yes

No

Do you use any over-the-counter supplements for energy or sexual health?(Required)

No

Yes

Do you have a history of melanoma or skin cancer?(Required)

No

Yes

Have you noticed any suspicious moles or skin changes under medical observation?(Required)

No

Yes

Have you noticed any suspicious moles or skin changes that are being monitored?(Required)

No

Yes

Are you pregnant, trying to conceive, or breastfeeding?(Required)

No

Yes

Not Applicable

Are you currently experiencing low libido or sexual performance concerns?(Required)

No

Yes

Are you aware of and comfortable with potential side effects like flushing, nausea, or increased blood pressure?(Required)

No

Yes

Do you consume alcohol regularly or use recreational drugs?(Required)

No

Yes

Do you have a history of mood disorders, anxiety, or depression?(Required)

Yes

No

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