info@pandaygroup.com | 905 773 7939

 

GetFitOver40 - TRT/HGH/HCG Patient Assessment Form

GetFitOver40 & The Panday Group are dedicated to providing patients with a telehealth prescription service for Testosterone Replacement Therapy (TRT), Human Growth Hormone (HGH) and Human Chorionic Gonadotropin (hCG) across Canada. Our performance assessment form provides our licensed health practitioners with a full overview of your daily and life habits. We ask all patients to provide as much information as possible about their daily lifestyle, habits and goals. This form should take approximately 20 - 30 mins. For additional information please email us at medical@pandaygroup.com

Name(Required)
Please place the address you would like your medication delivered too(Required)
Medication delivery can be sent anywhere across Canada
What's your gender(Required)
We understand these options aren't comprehensive, but this is for hormonal purposes
Marital Status(Required)
MM slash DD slash YYYY
Example: 5 ft 7"
Drop files here or
Accepted file types: jpg, jpeg, ldf, gif, png, Max. file size: 80 MB, Max. files: 4.
    Forms of government identification include driver's license, health card, passport etc. We do not bill any provincial insurance
    Drop files here or
    Accepted file types: jpg, jpeg, ldf, gif, png, Max. file size: 80 MB, Max. files: 4.
      **Patients that require bloodwork will be provided with a requisition before their appointment with our licensed health practitioner**
      Do you have medical bloodwork documents ?(Required)
      **Patients that require bloodwork will be provided with a requisition before their appointment with a licensed health practitioner. **
      How can we help you today ?(Required)
      Please indicate which therapy treatment you were looking to address with our health practitioner.
      What brings you in (Select all that applies)(Required)
      Please describe why testosterone/growth hormones are being requested
      How long have the above symptoms been occurring? (Select one)(Required)
      Do any of the below improve your symptoms? (Select any that apply)(Required)
      Do you smoke tobacco, vape nicotine, and/or use other tobacco products?(Required)
      Have you had blood work done to check for diabetes in the last 2 years?(Required)
      What was your most recent blood pressure reading?(Required)
      Your blood pressure helps us determine if it is safe for you to use certain types of ED medications. We require that you are honest about your blood pressure and that your blood pressure was taken within the last 6 months.
      Confirm(Required)
      Was your blood work normal?(Required)
      Describe your experience when you walk up two flights of stairs or 20 blocks on flat terrain:(Required)
      Do you use any recreational drugs? Some drugs may cause life-threatening interactions with ED medications.(Required)
      Select all that apply
      Are big life changes or stressors happening to you right now?(Required)
      Agreement(Required)
      Do any of the following currently apply to you?(Required)
      Select all that apply
      Have you ever had any of the following medical conditions?(Required)
      Select all that apply
      Do you have any allergies(Required)
      This information is important. Enter all types of allergies, including skin allergies and reactions.
      Do you take any medication, vitamins, herbals, or supplements?
      Please enter all medications you currently take, including any and all medications containing Nitroglycerine as well as vitamins, herbals, and supplements.
      Have you had any surgeries or hospitalizations?
      Please enter any and all past surgeries below
      Do you have any medical conditions?
      Please enter any and all medical conditions below

      PHQ-9- Patient Health Questionnaire

      Over the last 2 weeks, on how many days have you been bothered by any of the following problems?
      1. Little interest or pleasure in doing things(Required)
      2. Feeling down, depressed or hopeless(Required)
      3. Trouble falling or staying asleep, orsleeping too much(Required)
      4. Feeling tired or having little energy(Required)
      5. Poor appetite or over eating(Required)
      6. Feeling bad about yourself-or that youare a failure or have let yourself or your family down(Required)
      7. Trouble concentrating on things, such asreading the newspaper or watching television(Required)
      8. Moving or speaking so slowly that otherpeople could have noticed, or the opposite-being so fidgety or restless that you have been moving around a lot more than usual(Required)
      9.Thoughts that you would be better offdead, or of hurting yourself(Required)
      If you checked off any problems, how difficulty have these made it for you to do your work, take care of things at home, or get along with other people?(Required)

      GAD-7 Generalized Anxiety Disorder

      Over the last 2 weeks, on how many days have you been bothered by any of the following problems?
      1. Feeling nervous, anxious, or on edge(Required)
      2. Not being able to stop or control worrying(Required)
      3. Worrying too much about different things(Required)
      4. Trouble relaxing(Required)
      5. Being so restless that it's hard to sit still(Required)
      6. Becoming easily annoyed or irritable(Required)
      7. Feeling afraid as if something awful might happen(Required)
      If you checked off any problems, how difficulty have these made it for you to do your work, take care of things at home, or get along with other people?(Required)

      AMS Questionnaire

      Which of the following symptoms apply to you at this time? Please mark the appropriate box for each symptom. For symptoms that do not apply, please mark "none"
      Decline in your feeling of general well-being(Required)
      (general state of health, subjective feeling)
      Joint pain and muscular ache(Required)
      (lower back pain, joint pain, pain in a limb, general back ache)
      Excessive sweating(Required)
      (unexpected/sudden episodes of sweating, hot flashes independent of strain)
      Sleep Problems(Required)
      (difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)
      Increased need for sleep, often feeling tired(Required)
      Irritability(Required)
      (feeling aggressive, easily upset about little things, moody) .
      Nervousness(Required)
      (inner tension, restlessness, feeling fidgety)
      Anxiety(Required)
      (feeling panicky)
      Physical exhaustion / lacking vitality(Required)
      (general decrease in performance, reduced activity, lacking interest in leisure activities, feeling of gelling less done, of achieving less, of having to force oneself to undertake activities)
      Decrease in muscular strength(Required)
      (feeling of weakness)
      Depressive mood(Required)
      (feeling down, sad, on the verge of tears, lack of drive. mood swings. feeling nothing is of any use)
      Feeling that you have passed your peak(Required)
      Feeling burnt out, having bit rock-bottom(Required)
      Decrease in beard growth(Required)
      Decrease in ability/frequency to perform sexually(Required)
      Decrease in the number of morning erections(Required)
      Decrease in sexual desire/libido(Required)
      (lacking pleasure in sex, lacking desire for sexual intercourse)

      Adult Growth Hormone Deficiency Assessment

      Listed below are some statements which people make about themselves. Read the list carefully and put a tick in the box marked YES if the statement applies to you. Tick the box marked NO if it does not apply to you. Please remember to answer every item. If you are not sure whether to answer YES or NO tick whichever answer you think is most true in general
      I have to struggle to finish jobs(Required)
      I often feel lonely even when I am with other people.(Required)
      I feel a strong need to sleep during the day(Required)
      I have to read things several times before they sink in.(Required)
      It is difficult for me to make friends.(Required)
      It takes a lot of effort for me to do simple tasks.(Required)
      I have difficulty controlling my emotions.(Required)
      I often lose track of what I want to say.(Required)
      I lack confidence(Required)
      I have to push myself to do things.(Required)
      I feel as if I let people down.(Required)
      I often feel very tense.(Required)
      I find it hard to mix with people.(Required)
      I feel worn out even when I’ve not done anything.(Required)
      There are times when I feel very low.(Required)
      I avoid responsibility if possible.(Required)
      I avoid mixing with people I don’t know well.(Required)
      I feel as if I am a burden to other people.(Required)
      I often forget what people have said to me.(Required)
      I find it difficult to plan ahead.(Required)
      I am easily irritated by other people.(Required)
      I often feel too tired to do the things I ought to do.(Required)
      I have to force myself to do all the things that need doing.(Required)
      I often have to force myself to stay awake.(Required)
      My memory lets me down.(Required)
      Have you got any other major symptoms?(Required)
      Please type above
      Payment of $100 will be requested for the health practitioner consult prior to the appointment. Payment must be made within 24 hrs of the request to ensure a health practitioner is available for the requested time and date. The remaining $100 will be requested ONLY if our health practitioner issues a prescription.
      Your healthcare practitioner will take your choice into consideration and prescribe the medication best suited for you.
      Medication payment will be requested prior to shipment. Please note all payments will be requested by Interact E-Transfer.