Confidential Medical History Form for Men "*" indicates required fields Step 1 of 7 14% Please fill out the form below and one of our trained hormone consultants will review your information and contact you. Date MM slash DD slash YYYY AgePlease enter a number from 13 to 113.First Name*Last Name*Date of Birth (mm/dd/yyyy) MM slash DD slash YYYY Phone (H/C)Phone (W)Address Street Address City State 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 Pacific ZIP Code Email* Preferred Method of ContactHeightWeightWaist Size inHow did you hear about us?Accept Evaluation Fee* Please note there is a $120.00 Evaluation Fee for each patient/history form. Please initial here for your acceptance and understanding of this fee. Our team will reach out to you to collect payment before evaluating. Initials* Info about Practitioner Practitioner’s NameAddressPhoneFamily PractitionerFamily Practitioner’s PhoneUrologistUrologist's PhoneAllergiesPlease check all that apply: Penicillin Morphine Dye allergies Pet allergies Codeine Aspirin Nitrate allergies Seasonal (pollen) Sulfa drug Food allergies Other No known allergies Please describe the allergic reaction you experienced and when it occurredOver-the-counter (OTC)Please check all products that you use occasionally or regularly. Check all that apply. Pain Reliever Combination Product, cough+cold reliever (ex: Triaminic) Aspirin Sleep Aids (ex: Excedrin PM, Unison, Sominex) Acetaminophen (ex: Tylenol) Antidiarrheals (ex: Imodium, Pepto Bismal, Kaopectate) Ibuprofen (ex: Motrin IB) Laxatives/stool softeners (ex: Doxidan, Correctol) Naproxen (ex: Aleve) Diet Aids/Weight loss products (ex: Dexatrim) Ketoprofen (ex: Orudis KT) Antacids (ex: Maalox, Mylanta) Cough Suppressant (ex: Robitussin DM) Acid Blockers (ex: Tagamet HB, Pepcid AC, Zantac 75) Antihistamine products (ex: Chlor-Trimeton) Decongestant products (ex: Sudafed) Other Over-the-counter (OTC) issuesSupplements- Nutritional/NaturalDo you use any of the following? Vitamin (ex: Multiple or single vitamins- B complex, E, C, beta carotene) Minerals (ex: Calcium, magnesium, chromium, colloidal minerals, various single minerals) Herbs (ex: Ginseng, ginkgo biloba, echinacea, other herbal medicinal teas, tinctures, remedies, etc.) Enzymes (ex: Digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.) Nutrition/protein supplements (ex: Shark cartilage, protein powders, amino acids, fish oils, etc.) Others (ex: Glucosamine, etc.) Nutritional Health: Please answer Yes or No to the questions below. If YES, how often & how much? Do you use tobacco?Do you use alcohol?Do you consume caffeine?Do you exercise? Medical Conditions/Diseases; please check all that apply to you Heart disease (ex: congestive heart failure) Lung condition (ex: asthma, emphysema, COPD) High cholesterol or lipids (ex: Hyperlipidemia) Diabetes High blood pressure (ex: hypertension) Arthritis or joints problems Cancer Depression Ulcers (stomach, esophagus) Epilepsy Thyroid disease Headaches/migraines Hormonal related issues Eye disease (ex: glaucoma, etc.) Blood clotting issues Others: please list- Other Medical Conditionals/DiseasesCurrent Prescription MedicationsMedications Name:Strength:Date Started:How often per day: Add RemovePrevious Prescription MedicationsMedications Name:Date Started:Date Stopped:Reason: Add RemoveWhat medical conditions have you been treated for in the last 5 years?Bone Size Small Medium Large Have you had any of the following tests performed? PSA Yes Date MM slash DD slash YYYY OutcomeColonoscopy Yes Date MM slash DD slash YYYY OutcomeAuto-immune Yes Date MM slash DD slash YYYY OutcomeRectal Yes Date MM slash DD slash YYYY OutcomeTesticular Exam Yes Date MM slash DD slash YYYY OutcomeBlood Pressure: Yes Date MM slash DD slash YYYY OutcomeCholesterol Yes Date MM slash DD slash YYYY OutcomeHDLLDLTriglyceridesThyroid test Yes Date MM slash DD slash YYYY OutcomeGlucose Yes Date MM slash DD slash YYYY OutcomeVitamin D Yes Date MM slash DD slash YYYY Outcome Do you have a family history of any of the following? Please check corresponding box and list Family Member(s) Cancer Yes Family Member(s) with CancerBreast Cancer Yes Family Member(s) with Breast CancerHeart Disease Yes Family Member(s) with Heart DiseaseOsteoporosis Yes Family Member(s) with OsteoporosisProstate Disease Yes Family Member(s) with Prostate DiseaseBPH Yes Family Member(s) with BPHDiabetes Yes Family Member(s) with DiabetesThyroid Disease Yes Family Member(s) with Thyroid Disease How did you arrive at the decision to consider Bio-Identical Testosterone Replacement Therapy? Doctor Self Friend/Family Member Other Have you discussed this therapy with your practitioner?Have you experienced a major trauma or loss in the last five years? Symptom Checklist Please consider the following symptoms and check the number that best matches your current status. “0” would indicate mild to no symptoms while ”3” would represent severe or frequent symptoms. Morning fatigue 0 1 2 3 Stress 0 1 2 3 General fatigue 0 1 2 3 Anxiety 0 1 2 3 Decreased stamina 0 1 2 3 Irritability 0 1 2 3 Difficulty sleeping 0 1 2 3 Depression 0 1 2 3 Decrease in fullness of erection. 0 1 2 3 Apathy 0 1 2 3 Increase in aches, joint and muscle pains 0 1 2 3 Weight gain in hips/waist 0 1 2 3 Decrease in muscle mass 0 1 2 3 Decreased flexibility 0 1 2 3 Decreased libido 0 1 2 3 Sugar craving 0 1 2 3 Decreased urine flow 0 1 2 3 Constipation 0 1 2 3 Increased urinary urge 0 1 2 3 Dry/brittle hair 0 1 2 3 Decrease in volume of ejaculate 0 1 2 3 Heart palpitations 0 1 2 3 Prostate Problems 0 1 2 3 Hoarseness 0 1 2 3 Loss of AM erection 0 1 2 3 Headaches 0 1 2 3 Decreased ability to concentrate 0 1 2 3 Cold body temp –hands & feet 0 1 2 3 More forgetful 0 1 2 3 Thinning skin 0 1 2 3 Decrease in interest in hobbies 0 1 2 3 Facial swelling/ puffy eyes 0 1 2 3 Hearing Loss 0 1 2 3 Rapid Aging 0 1 2 3 Please list any other symptoms you are experiencing Thank you for taking the time to complete this form. The information you have provided will be kept confidential and will assist the pharmacist in providing you with the most appropriate form of care and service. Please write down any other questions you may have. Additional Questions