Low Testosterone Patient Intake Form

Low Testosterone Patient Intake Form

The medical information you supply is subject to ALL patient/doctor privilege laws
Date of Birth*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Employment Status - Employer? Self-Employed? Retired?
Emergency contact

Full NamePhone Number
ParentSignificant OtherSiblingChildFriendOther
MEDICAL HISTORY
Chief Complaint: What is the reason you are seeking treatment?
What treatments have you received in the past for this condition?
Did you experience any side effect?
What are you hoping to achieve with treatment?
Do you have any allergies? Please list
TESTOSTERONE QUESTIONAIRE:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
DailyWeeklyMonthlyRarelyNever
PATIENT CURRENT and PAST MEDICAL HISTORY
Heart diseaseHypertensionPolycythemiaHigh cholesterolHyperlipidemiaStokeCancerProstate CancerThyroid diseaseKidney diseaseLiver diseaseHepatitisHIVSleep apneaHeart attackDiabetesPulmonary embolismBlood clotsEnlarged ProstateOther
List all Current Medical Conditions
List All Current Medications including dosage and frequency and any Supplements.
Surgical History
Additional Comments
FAMILY HISTORY
AliveDeceasedDiabetesHypertensionHeart DiseaseStrokeCancer
AliveDeceasedDiabetesHypertensionHeart DiseaseStrokeCancer
SOCIAL HISTORY
SingleDatingMarriedDivorcedWidowed
YesNo
YesNo
YesNo
Should be Empty: