Male BHRT Health Summary

Male Patient Information and Health Summary

Date

Name

Date of Birth

Date

Address

Street Address Line 2

City/State/ZIP

Home Phone

Please enter a valid phone number.Format: (000) 000-0000.

Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Fax Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Who referred you to us?

Please List Your Healthcare Provider to Contact Regarding Hormone Therapy

Name

Specialty

Address

Phone

Format: (000) 000-0000.

Fax

Please enter a valid phone number.Format: (000) 000-0000.

Any Known Medication Allergies?

Please List Any Medications You Are Currently Taking, Including Vitamins, Natural Supplements, or Non Prescription Medications (Doses of any hormones you are taking are necessary, because that is the current baseline to make a recommendation to your doctor)

Is your Diet:

Exercise--type of activity, how frequent, and for how long?

Height in FEET blanks and INCHESblank .

Weight in POUNDS:

Employer and Job Title

Your Perceived Stress Level:

Family History--Please check all that apply:

Please list which family member had which of these disease states (mother--breast cancer, brother--prostate cancer, etc.):

Personal Past or Present Medical Conditions--Please check all that apply:

Have you ever had--Check all that apply:

If you have used Previous Hormone Therapies before or are using them currently, please list the previous AND current hormones with the DOSES and any side effects:

Have you tried alternative therapies or taken any herbal or homeopathic products?

How did you become interested in bio identical hormones?

Please check all symptoms of low Progesterone:

Are you having symptoms of Insomnia, going to sleep or staying asleep?

If you are having insomnia, how many times per week?

If you are having headaches, how many times per week?

Please check all symptoms of Low Testosterone

Any other symptoms not listed?

Top 3 symptoms you'd like resolved first:

Degree of Insomnia or restless, fragmented sleep?

Intensity of Irritability, feeling anxious or apprehensive?

Degree of feelings of Depression & unhappiness and/or being miserable without obvious reason?

Degree of sensations of Dizziness or swimming in the head?

Degree of feeling of Weariness of mind/body with desire for rest; disinclination to make further efforts?

Degree of Pain of any kind affecting joints or muscles?

Severity of Headaches of any kind (tension, migraine, etc.)?

Degree of quickening or acceleration of Heartbeat of fluttering/pounding heartbeat in a sitting or resting position?

Have you ever had Painful Urination or increased frequency of urination?

Have you ever had Leaking of Urine when coughing, laughing, sneezing, or on hard work?

Have you ever had Leaking of Urine when walking, running, climbing steps, or on light work?

Have you ever had Leaking of Urine, regardless of activity, even when in a lying position?