MEN’S CONFIDENTIAL HEALTH QUESTIONNAIRE

MEN’S CONFIDENTIAL HEALTH QUESTIONNAIRE

43875 Washington Street, Suite C, Palm Desert, CA 92211 Ph.: 1-833-935-6377 I email: info@palmspringswellness.com I Fax: 1-833-935-6377
Today's Date:

Month Day Year
Date
Name *

First Name Last Name
Height:
Weight:
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Birthdate: *
Age: *
Gender *

Male Female
Do you use Tobacco? *

Yes No
If yes, how often and how much?
Do you use alcohol? *

Yes No
If yes, how often and how much?
Do you use Caffeine? *

Yes No
If yes, how often and how much?
Any illicit drug use? *

Yes No
Allergies (please state)
Please describe the allergic reaction you experienced:
Please list all OTCs (Over-the-Counter) items you are currently taking:
Please list all Nutritional/Natural Supplements you are currently using:
Please enter your Doctors Name
Please enter your Doctors Phone Number
Medical Conditions/Diseases: Please Check all that apply to you:

Heart disease (example: Congestive HeartFailure) High cholesterol or lipids (examples:Hyperlipidemia) High blood pressure (example:Hypertension) Cancer Ulcers (stomach, esophagus) Thyroid disease Hormonal related issues Lung condition (example: Asthma,Emphysema, COPD) Blood Clotting/Bleeding Disorders Diabetes Arthritis or Joint problems Depression Seizures Headaches/Migraines Eye disease (Glaucoma, Cataract, etc.) Stroke Other

Current Prescription Medication including Hormones that you take or have taken:

How did you decide to consider Bio-Identical Hormone Replacement Therapy(BHRT)?

Doctor Self Friend/Family Member Other
What are your goals with taking BHRT?

Symptoms: Please select the one that best applies. *

	Absent	Mild	Moderate	Severe
Fatigue
Decrease in muscle mass
Loss in muscle strength
Increase in joint and muscle pain
Increase in waist size
Trouble losing weight
Loss in height
Decrease in sex drive
Difficulty in establishing/maintaining full erection
Decrease in spontaneous early morning erection
Change in sleep pattern
Decrease in mental sharpness
Trouble concentrating
Less enjoyment in personal interests/hobbies

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