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(910) 239-5905 |
Cosmetic Surgery
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Procedures
Emsculpt NEO
Emsella
Wellness
About & Patient Testimonials
Are You a Candidate?
Bio-Identical Hormone Replacement Therapy
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Female Rejuvenation
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CONSULTATION
Advanced Liposculpture Procedures
Smartlipo™
Smartlipo™ Arms
Tricontour™
Smartlipo™ Abdomen
Smartlipo™ Legs and Thighs
Renuvion Skin Tightening
Smartlipo™ Waist and Back
Military Waist Reduction
Cellulite
Cellulaze
Skin & Body
Skin Rejuvenation
Skin Resurfacing
Skin Tightening
Feminine Rejuvenation
Are You a Candidate?
Women
Men
Health Assessment for Women
Symptoms
(Please Pick One for Each Symptom)
Depressive mood
*
Never
Mild
Moderate
Severe
Memory Loss
*
Never
Mild
Moderate
Severe
Mental confusion
*
Never
Mild
Moderate
Severe
Decreased sex drive/libido
*
Never
Mild
Moderate
Severe
Sleep problems
*
Never
Mild
Moderate
Severe
Mood changes/Irritability
*
Never
Mild
Moderate
Severe
Tension
*
Never
Mild
Moderate
Severe
Migraine/severe headaches
*
Never
Mild
Moderate
Severe
Difficult to climax sexually
*
Never
Mild
Moderate
Severe
Bloating
*
Never
Mild
Moderate
Severe
Weight gain
*
Never
Mild
Moderate
Severe
Breast Tenderness
*
Never
Mild
Moderate
Severe
Vaginal dryness
*
Never
Mild
Moderate
Severe
Hot flashes
*
Never
Mild
Moderate
Severe
Night sweats
*
Never
Mild
Moderate
Severe
Dry and wrinkled skin
*
Never
Mild
Moderate
Severe
Hair falling out
*
Never
Mild
Moderate
Severe
Cold all the time
*
Never
Mild
Moderate
Severe
Swelling all over the body
*
Never
Mild
Moderate
Severe
Joint pain
*
Never
Mild
Moderate
Severe
Family History
Heart Disease
*
NO
YES
Diabetes
*
NO
YES
Osteoporosis
*
NO
YES
Alzheimer's Disease
*
NO
YES
Breast Cancer
*
NO
YES
Name
*
First
Last
Phone
*
Email
*
Health Assessment for Men
Symptoms
(Please Pick One for Each Symptom)
Decline in general well being
*
Never
Mild
Moderate
Severe
Joint pain/muscle ache
*
Never
Mild
Moderate
Severe
Excessive sweating
*
Never
Mild
Moderate
Severe
Sleep problems
*
Never
Mild
Moderate
Severe
Increased need for sleep
*
Never
Mild
Moderate
Severe
Irritability
*
Never
Mild
Moderate
Severe
Nervousness
*
Never
Mild
Moderate
Severe
Anxiety
*
Never
Mild
Moderate
Severe
Depressed mood
*
Never
Mild
Moderate
Severe
Exhaustion/lacking vitality
*
Never
Mild
Moderate
Severe
Declining Mental Ability/Focus/>Concentration
*
Never
Mild
Moderate
Severe
Feeling you have passed your peak
*
Never
Mild
Moderate
Severe
Feeling burned out/hit rock bottom
*
Never
Mild
Moderate
Severe
Decreased muscle strength
*
Never
Mild
Moderate
Severe
Weight Gain/Belly Fat/Inability to Lose Weight
*
Never
Mild
Moderate
Severe
Breast Development
*
Never
Mild
Moderate
Severe
Shrinking Testicles
*
Never
Mild
Moderate
Severe
Rapid Hair Loss
*
Never
Mild
Moderate
Severe
Decrease in beard growth
*
Never
Mild
Moderate
Severe
New Migraine Headaches
*
Never
Mild
Moderate
Severe
Decreased desire/libido
*
Never
Mild
Moderate
Severe
Family History
Heart Disease
*
NO
YES
Diabetes
*
NO
YES
Osteoporosis
*
NO
YES
Alzheimer's Disease
*
NO
YES
Name
*
First
Last
Phone
*
Email
*