Patient Medical History Form

SouthPointe Plaza

1901 E 32nd St Ste 20

Joplin MO

(417) 781-2046

www.apclinic.net
Male Hormone Symptom Checklist
Date*

MonthDayYear
Date
Patient Name*

First NameMiddle NameLast Name
Patient Birth Date*

MonthDayYear
How would you describe your health at the present?

Very goodGoodFairPoorVery poor
How much do your think your bladder problems affect your life?

Not at allA littleModeratelyA lot
How would you describe your health at the present?
Category 1 | Sex Hormone Imbalance

ApathyBurned out feelingDecreased erectionsDecreased libidoDecreased mental sharpnessDecreased muscle massDecreased staminaDecreased urine flowErectile dysfunctionHot flashesIncreased urinary urgeInfertility problemsInsomniaIrritableNight sweatsOily skinProstate problemsSleep disturbancesWeight gain waist
Category 2 | Adrenal Hormone Imbalance

Aches/painsAfternoon/evening fatigueAllergiesAnxietyAutoimmune diseaseBone lossChronic health problemsDecreased erectionsDepressionFibromyalgiaLow blood sugarLack of motivationMorning fatigueProstate problemsSleep disturbancesStressSusceptibility to infectionsWeight gain waist
Category 3 | Thyroid Hormone Imbalance

Brittle nailsConstipationDecreased erectionsDepressionDry skinElevated cholesterolFatigueFeeling coldFoggy thinkingHeadachesHeart palpitationsInfertilityInability to lose weightLack of motivationLow libidoSleep disturbances
Category 4 | Metabolic Imbalance

Diabetes (or family history)Elevated cholesterolFatigueHeart disease/stroke (or family history)High blood pressureHigh blood sugarInsulin resistanceLow libido/decreased sexual functionLow physical activitySalt/sugar cravingsSmoking (or history of)Thyroid disordersWeight gain
Category 5 | Neurotransmitter Imbalance

ADD?ADHDAddictive behaviorsAggressive behaviorAnxious/nervousApathyAutism spectrum disorderDepressedDevelopmental delaysDifficulty sleepingEating disordersIrritableManiaMethylation deficitsOCDPanic attacks
Do you have difficulty with?

Obtaining erectionMaintaining erectionBoth
Have you received treatment for erectile dysfunction or premature ejaculation?

YesNo
How often were you able to get an erection during sexual activity?

No sexual activityAlmost neverA few timesSometimes (about half the time)Most timesAlmost always
When you had erections with sexual stimulation, how often were your erections hard enough for penetration?

No sexual activityAlmost neverA few timesSometimes (about half the time)Most timesAlmost always
During intercourse, how often were you able to maintain your erection after you have penetrated your partner?

Did not attemptAlmost neverA few timesSometimes (about half the time)Most timesAlmost always
Should be Empty:

Male Hormone Symptom Checklist