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
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
Should be Empty:

Male Hormone Symptom Checklist