Mens Hormone Health Profile/Questionnaire

MENS HORMONE HEALTH PROFILE/QUESTIONNAIRE

This information will be reviewed by our certified hormone specialist in order to provide a custom-tailored prescription to fit your needs. Thank you for taking the time to complete this comprehensive questionnaire!
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Height (in inches)*
Weight (in pounds)*
BMI (Pharmacist will calculate)
Waist Circumference*
Waist Hip - Ratio*
Allergies - Please check all that apply:*

No known drug allergiesMorphinePenicillinCodeineSulfaAspirinFood AllergiesDye AllergiesNitrate AllergiesPet AllergiesSeasonal Allergies
Please describe the allergic reaction you experienced when it occurred?
Current Prescription Medications (Name / Strength / Date Started / How Often Per Day)
Over-the-counter (OTC) Medications: Please check all products that you use occasionally or regularly. Check all that apply.

Pain RelieverAntihistamine Product (ex: benadryl)AspirinCombination Product (cough + cold reliever)Acetaminophen (ex: Tylenol)Sleep aids (ex: Unisom)Ibuprofen (ex: Motrin)Antidiarrheals (ex: Imodium)Naproxen (ex: Aleve)Laxatives/stool softenersKetoprofenDiet aids/weight loss productsCough Suppressant (ex: Robitussin DM)Antacids (ex: Maalox)Acid Blockers (rx: Pepcid)Decongestants (ex: Sudafed)Other
Nutritional/Natural Supplements: Please check all products that you use occasionally or regularly. Check all that apply:

Vitamins (examples: multiple or single vitamins such as B complex, E, C, beta carotene)Minerals (examples: calcium, magnesium, chromium, colloidal minerals, various single minerals)Herbs (examples: Ginseng, Ginkgo Biloba, Echinacea, other herbal medicinal teas, tinctures, remedies, etc.)Enzymes (examples: digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.)Nutrition/protein supplements (examples: shark cartilage, protein powers, amino acids, fish oils, etc.)Other
Please List the nutritional/natural supplement products that you take:
Medical Conditions/Social History: Please check all that apply to you.

Heart disease (example: Congestive Heart Failure)High cholesterol or lipids (examples: Hyperlipidemia)High blood pressure (example: Hypertension)CancerUlcers (stomach, esophagus)Thyroid diseaseHormonal Related IssuesLung condition (example: asthma, emphysema, COPD)Blood Clotting ProblemsDiabetesArthritis or joint problemsDepressionEpilepsyHeadaches/migrainesEye Disease (glaucoma, etc.)Cardiovascular DiseaseTobacco UseAlcohol UseDepressionMalnutritionOther

Please indicate if you are experiencing any of the following symptoms:

	ABSENT	MILD	MODERATE	SEVERE
Fatigue
Decreased Muscle Mass
Loss in Muscle Strength
Joint/Muscle Pain
Increase in Waist Size
Difficulty Losing Weight
Decreased Height
Decreased Sex Drive
Difficulty Establishing and/or maintaining full erections
Decrease in Spontaneous Early Morning Erections
Changes in Sleep Patterns
Decreased Mental Sharpness
Trouble Concentrating
Less Enjoyment in Personal Interests and Hobbies

I am(please type age)* years old. I feel (please type age)* years old.
Please write down any questions you have about Bio-Identical Hormone Replacement Therapy.*
Please Include a copy of all relevant lab work, especially hormone levels that you have recently obtained
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MENS HORMONE HEALTH PROFILE/QUESTIONNAIRE

Please Include a copy of all relevant lab work, especially hormone levels that you have recently obtained