Secure patient form

Men's health intake

Hormone and peptide visit only. Not a medical cannabis evaluation. Please complete every section before your consultation with Dr. Ewals. Bring a photo ID and any recent labs. We do not bill insurance.

Tiredness, low libido or poor sleep can come from sleep problems, stress, medicines, weight, thyroid or low testosterone. Your answers help her see the whole picture. They are not a diagnosis. Need a lab order? Call Will at (218) 274‑4500.

Have an emergency? Call 911 or go to the nearest emergency room.

Required

Visit type

Which visit is this? (required)
How will you be seen? (required)

Patient information

Your name as it appears on your photo ID.

Sex

Optional. Consent is not a condition of care.

As it appears on your photo ID.

State (required)

We see North Dakota and Minnesota residents only. Moving here? Call Will at (218) 274‑4500.

Bring the ID itself to your visit.

The front of your driver's license or state ID, as a photo or PDF, up to 15 MB. Or just bring it to your visit.

Optional.

What you want this visit to address

Check what applies.

What's been going on?
Symptom severity today (required)

0 = none, 10 = worst.

Hormone and peptide history

Prior testosterone therapy? (required)
Have you ever had peptide or hormone therapy? (required)
Any side effects from those treatments?
When was the last time you had blood work done? (required)

Bring or send the results. Labs can be faxed to (701) 757‑0974.

Do you plan on having children? (required)

TRT can lower sperm count.

Medical history

Please check any that apply to you.

Medications and allergies

Are you currently taking any prescribed medications? (required)

Add any over-the-counter medicines and supplements too. Include testosterone boosters and workout supplements.

Do you have any drug allergies? (required)

Daily habits

Exercise
Type of exercise
Tobacco
Do you drink alcohol?
Do you use cannabis?
Diagnosed sleep apnea?

Acknowledgments

Signature

Typing your full legal name here is your electronic signature.

Leave blank if you are the patient.

Sent privately to our care team

Your information is kept private and used only to contact you about your care.