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?
How much do your think your bladder problems affect your life?
How would you describe your health at the present?
Category 1 | Sex Hormone Imbalance
Category 2 | Adrenal Hormone Imbalance
Category 3 | Thyroid Hormone Imbalance
Category 4 | Metabolic Imbalance
Category 5 | Neurotransmitter Imbalance
Do you have difficulty with?
Have you received treatment for erectile dysfunction or premature ejaculation?
How often were you able to get an erection during sexual activity?
When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
During intercourse, how often were you able to maintain your erection after you have penetrated your partner?
Should be Empty:

Male Hormone Symptom Checklist