Biomarker Assessment Questionnaire

Health Information:

What is your gender?

Male
Female

What's your height?

Feet

Inches

Current Weight (in pounds)

Do you have any known allergies?

Yes
No

Please list

Do you have any chronic conditions?

Yes
No

Please specify

Lifestyle and Diet:

Describe your current diet:

How often do you exercise?

Daily
Weekly
Rarely
Never

How would you rate your stress levels?

Low
Moderate
High

Medical History:

Do you have a family history of any of the following conditions?

Please specify

List any medications or supplements you are currently taking:

Have you had any previous hormone replacement therapy (HRT)?

Yes
No

Please specify

Specific Interests and Goals:

What are your primary health goals?

Please specify

What specific outcomes are you looking to achieve from the biomarker assessment?

Do you have any specific health concerns you would like to address?

Yes
No

Please specify

Biomarker Testing:

For Men

Are you interested in Hormone Replacement Therapy (HRT)?

Yes
No

For Women

Are you interested in Hormone Replacement Therapy (HRT)?

Yes
No

For Men

Hormone Replacement Therapy (HRT) Specifics:

Testosterone Levels:

Do you have any concerns regarding your testosterone levels?

Yes
No

Please specify

Free Testosterone Levels:

Are you aware of your free testosterone levels?

Yes
No

Prostate-Specific Antigen (PSA) Levels:

Have you had your PSA levels checked before?

Yes
No

Estradiol Levels:

Do you have any concerns regarding your estradiol levels?

Yes
No

For Women:

Hormone Replacement Therapy (HRT) Specifics:

Estradiol Levels:

Are you aware of your estradiol levels?

Yes
No

Follicle-Stimulating Hormone (FSH) Levels:

Have you had your FSH levels checked before?

Yes
No

Progesterone Levels:

Do you have any concerns regarding your progesterone levels?

Yes
No

Testosterone Levels:

Are you aware of your testosterone levels?

Yes
No

Additional Information:

Is there any other information you feel is relevant for Dr. Martinez to know?

How much do you budget for your wellness each year?

Less than $1000
More than $1000. Less than $10,000
More than $10,000

We know this question may feel personal—but it's important. It helps us prioritize patients who are committed to long-term results, and tailor recommendations that make sense financially and medically.

In the last 3–6 months, what’s been the most frustrating part about your health, energy, or appearance? Please be as specific as possible

(numbers on the scale, lab results, clothes that don’t fit, comments from others, photos you didn’t like, etc.).

Can you describe a recent moment when this problem really bothered you or got in the way of your life? What happened, and how did it make you feel?

Enter your zip code

We need to make sure your state allows telehealth.

Name

First

Last

Email

Phone

How did you hear about us?

Please specify

Our clinic is located in Hallandale, Florida, are you nearby?

Yes
I can make it
No, but I'm OK with a virtual consultation

If you live far, we do offer virtual consultations