HYLANE™ Treatment Form "*" indicates required fields 01 • Personal InformationName* First Last Email* Phone*City of Residence*State of Residence*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificWhat is your age?*Date of Birth* MM slash DD slash YYYY 02 • Medical BackgroundPlease list your top five symptoms:*What results are you seeking?*03 • Lifestyles & ActivitiesDo you enjoy competitive activities?* Yes No On a scale of 1 to 5, with 5 being the most ambitious, how ambitious are you?* 1 2 3 4 5 On a scale of 1 to 5, with 5 being the most disciplined, how disciplined are you?* 1 2 3 4 5 Physician fees are out of pocket, and they do not participate in any insurance plans including medicare or medicaid. Is this workable for you?* Yes No There are usually specialty tests whose fees are directly payable to the laboratory, which are not covered by insurance, is this acceptable?* Yes No Are you free of substance use such as alcohol or recreational drugs?* Yes No Rate your ability to organize and follow through on tasks in your current condition:* Unable to do so Sometimes can Frequently able Able to all the time Do you have an emotionally supportive other living with you?*Their relationship to you:*Do you have someone who can keep you organized living with you?*Eating healthy meals daily: No support Occasional support Support several times/week Daily support Finding good doctors/care: No support Occasional support Support several times/week Daily support Help with tasks you're unable to do (e.g., shopping, cleaning): No support Occasional support Support several times/week Daily support Have you engaged in self-destructive behaviors (e.g., self-harm, anorexia, substance abuse)? Please elaborate:*How were you referred to us: Physician Dr. Mark Hyman's Podcast Cleveland Clinic Georgetown Univ School of Medicine
