GENTLE GIANT CARE MALE PATIENT QUESTIONNAIRE AND HISTORY FORM

MALE PATIENT QUESTIONNAIRE AND HISTORY FORM

600 Peachtree Parkway, Ste 104 Cumming GA, 30041

Name*
(Last) (First) (Middle)
Today’s Date*

MonthDayYear
Date of Birth*

MonthDayYear
Date
Age*
Weight*
Occupation*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Work*
Please enter a valid phone number.
Email*
example@example.com
May we contact you via E-Mail?*

YESNO
In Case of Emergency Contact*
Please enter a valid phone number.
Relationship*
Home Phone*
Please enter a valid phone number.
Work*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Primary Care Physician’s Name*
Phone*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Marital Status (Check One)*

MarriedDivorcedWidowLiving with PartnerSingle
In the event we cannot contact you by the mean’s you’ve provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment.
Spouse’s Name*
Relationship*
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Social: (Check all that Apply)*

I am sexually active.I want to be sexually active.I have completed my family.I have used steroids in the past for athletic purposes.
Habits: (Check all that Apply)
I use blankscaffeine per day.
I smoke blankscigarettes or cigars per day
I drink blanksalcoholic beverages per day
I drink more than 10 alcoholic beverages per week.
Any known drug allergies*
Have you ever had any issues with anesthesia?*

YESNO
If yes please explain*
Medications Currently Taking*
Current Hormone Replacement Therapy*
Past Hormone Replacement Therapy*
Nutritional/Vitamin Supplements*
Surgeries, list all and when*
Other Pertinent Information*
MEDICAL ILLNESSES*

High blood pressure. ( ) High cholesterol.Heart Disease.Stroke and/or heart attackBlood clot and/or a pulmonary emboli.Hemochromatosis.Depression/anxiety.Psychiatric DisorderCancer
Testicular or prostate cancerElevated PSA.Prostate enlargement.Trouble passing urine or take Flomax or Avodart.Chronic liver disease (hepatitis, fatty liver, cirrhosis)Diabetes.Thyroid diseaseArthritis.
I understand that if I begin testosterone replacement with any testosterone treatment, including testosterone pellets, that I will produce less testosterone from my testicles and if I stop replacement, I may experience a temporary decrease in my testosterone production. Testosterone Pellets should be completely out of your system in 12 months.

By beginning treatment, I accept all the risks of therapy stated herein and future risks that might be reported. I understand that higher than normal physiologic levels may be reached to create the necessary hormonal balance
Print Name*
Signature*

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Date

MonthDayYear
Should be Empty:

MALE PATIENT QUESTIONNAIRE AND HISTORY FORM

Habits: (Check all that Apply)