Men's Health Survey

Men's Health Survey
Do you RESIDE in the following states: MI, FL, MN, OH, or WI?
I'm sorry, we are not able to serve your location at the moment. Please contact your local compounding pharmacy.
Doctor's Name

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Personal Information - Page 1 of 6
Today's Date

MonthDayYear
Date
Personal Information
Name

First NameLast Name
Age
Birthdate

MonthDayYear
Date
Your aAddress

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home or Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
Occupation

Health Information - Page 2 of 9
What is your greatest need or problem? (List the most important, then list other issues in order of importance):
Your current medical conditions or diagnoses:
Drug allergies:
Allergies to food, pollens, environment, etc.:
Names of ALL prescription medications taken in the last 6 months. Include strength and how you take them.
List ALL vitamins, supplements, non-prescription medicines, or other OTC products that you are currently using:
Indicate any herbal products you have taken. (Evening Primrose oil (EPO), Chaste Tree Berry, Dong Qual, Black Cohosh, Gensing, Melatonin, etc. or other)
Drug allergies

Health Information Continued - Page 4 of 9
How much water do you drink in one day (24 hr)?
Measured in:
Where is your drinking water from?
Dietary restrictions (such as salt, carbohydrates, milk products, red meat, etc):
When was your latest general medical exam?

MonthDayYear
Date
Name of Primary Health Care Practitioner/Physician
Primary Practitioner/Physician Phone Number
Primary Practitioner/Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Physician currently seeing:

Rows	Not Applicable	Mild	Moderate	Severe
Do you feel more fatigued and/or tired than usual?
Have you noticed a decrease in your muscle mass?
Have you experienced a loss in muscle strength?
Have you experienced an increase in joint and/or muscle pains?
Have you noticed an increase in your waist size?
Do you have trouble losing weight?
Have you experienced a loss in height?
Do you have a decrease in your sex drive?
Have you experienced difficulty in establishing and/or maintaining full erections?
Have you experienced changes in your usual sleep pattern?
Do you feel a decrease in your mental sharpness?
Have you had trouble concentrating?
Do you experience less enjoyment in personal interests and hobbies?
Are you sad and/or grumpy?
Are you falling asleep after dinner?
Has there been a recent deterioration in your work performance?
Have you noticed a recent deterioration in your ability to play sports?