Patient Information
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Height
Weight
Medical & Social History: Please check the following that apply to you.
High Blood Pressure
High Cholesterol
Cardiovascular Disease
Diabetes Mellitus
Osteoporosis
Benign Prostatic Hyperplasia
Tobacco Use
Asthma/COPD
Alcohol Use
Erectile Dysfunction
Insomnia
Malnutrition
Depression
Cancer
Other
Medical History: List all prescription and non-prescription medications that you are taking. (Including vitamins, herbals and supplements.)
Drug Allergies:
Please indicate if you are experiencing the following symptoms:
Absent
Mild
Moderate
Severe
Fatigue
Decreased muscle mass
Loss in muscle strength
Join/Muscle Pain
Increase in waist size
Difficulty losing weight
Decreased height
Decreased sex drive
Difficulty establishing and/or maintaining full erections
Decrease in spontaneous early morning erections
Changes in sleep patterns
Decreased mental sharpness
Trouble concentrating
Less enjoyment in personal interests and hobbies
How old are you?
How old do you feel?
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