AGELESS HEALTH INNOVATIONS
Patient Health History: MEN
Date
-
Month
-
Day
Year
Date
Chart # (administrative use only)
Patient Name
First Name
Middle Name/Initial
Last Name
Date of last Physical Exam (month + year)
Primary Care Doctor (PCP):
Personal Health History
Check all that apply
Cardiovascular disease
Chest pain
Heart failure
Murmur
Vascular disease
Blood clots
Fainting
Lower extremity edema
None
Other
Respiratory disease
Shortness of breath
Asthma
Bronchitis
Pneumonia
Allergies
Hay fever
None
Other
Gastrointestinal disease:
Lactose intolerance
Gallbladder
Gall stones
Diarrhea
Constipation
None
Other
Genitourinary disease:
Overactive bladder
Frequent urination
Painful urination
Difficult urination
Prostate enlargement
BPH
Diabetes
High Blood Pressure
Cancer
Depression
High Cholesterol
Sleep Apnea
None
Other
Surgeries
Rows
Year
Surgery
City+State
List your prescribed medications and over-the-counter drugs, such as vitamins and inhalers here OR, use the box below to upload a picture or document listing your medications
Rows
Name the Medicine
Strength
Frequency Taken
Upload a picture or document listing your medications
Browse Files
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of
Allergies To Medications
Rows
Name The Drug
Reaction You Had
.
.
.
Health Habits And Personal Safety
Exercise
None at this time
Occasionally
Regularly
Mild
Vigorous
Other
Alcohol
Yes
No
Tobacco
Yes
No
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Ageless Health Innovations
Patient Health History: MEN
Urogenital Health: Please answer "Yes" or "No" to each question
Rows
Yes
No
Do you feel pain or burning with urination?
Any blood in your urine?
Do you feel burning discharge from penis?
Has the force of your urination decreased?
Have you had any kidney, bladder, or prostate infections within the last 12 months?
Do you have any problems emptying your bladder completely?
Any difficulty with erection or ejaculation?
Any testicle pain or swelling?
Date of last Prostate / Rectal Exam (month + year -- or, haven't had one)
Date of last colonoscopy-- or, insurance approved at-home colon cancer screening i.e.: Cologuard (month + year -- or, haven't had one)
Symptoms of low Testosterone levels please answer "Yes" or "No" to each symptom
Rows
Yes
No
Difficulty concentrating
Moodiness
Depression
Weight Gain
Decreasing sex drive
Increasing Fatigue
Decreasing energy
Daytime Sleepiness
Poor Sleep Habits
Erectile Dysfunction
REVIEW + SIGNATURE
I have received or reviewed the Privacy Practices Notice for Ageless Health Innovations (three (3) pages, link for review below). I understand the situations in which this practice may need to utilize or release my medical records. I understand that this office will properly maintain my records and will use all due means to protect my privacy as outlined in this Privacy Practice Notice.
Your signature constitutes your understanding of the above information.
Date
/
Month
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Day
Year
PRIVACY PRACTICES REVIEWABLE HERE
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