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TESTOSTERONE MEN’S INTAKE FORM
Name
*
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Height
Weight
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Occupation
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health History Questionnaire
Personal Health History – Check all that apply.
General
Diabetes
HighCholestero
Unwanted Weight Loss
Cancer
Personal History of Cancer
Family History of Cancer
Autoimmune Disorder
Cardiovascular
Heart Failure
Heart Attack
Heart Murmur
Vascular Disease
Blood Clots
Edema
Hypertension
Irregular heartbeat
Congestive Heart Failure
Respiratory
Sleep Apnea
Shortness ofbreath
Asthma / COPD
Bronchitis
Pneumonia
Allergies
Gastrointestinal
LactoseIntolerance
Gall Bladder
Gall Stones
Genitourinary
Chronic Diarrhea
Chronic Constipation
Prostate Cancer
Familial Prostate Cancer
Overactive Bladder
Painful Urination
Decreased urinary force
Blood in Urine
On/Off Urine Flow
Enlarged Prostate (BPH)
Kidney/Bladder History
Infection
Kidney/Bladder
Liver
Psychiatric
History of Depression
Personality Disorder
List your prescribed drugs and any over-the-counter drugs, such as vitamins and inhalers.
Drug Name
Dosage
Frequency
Taken for
Drug Name
Dosage
Frequency
Taken for
Drug Name
Dosage
Frequency
Taken for
Allergies:
No Known Allergies Or List Allergies and Reaction
Surgeries
Year
Surgery/Reason
Year
Surgery/Reason
Health Habit and Personal Safety
Exercise
None
Mild
Occasional vigorous exercise
Regular vigorous exercise
Describe type of exercise and frequency (resistance training, cardiovascular, number of times per week)
Have you used Testosterone (prescribed or otherwise) or any other anabolic steroids in the past? Pleasebe completely truthful with your response, it is critical to diagnose and prescribe correctly.
Rate your quality of sleep: 1-Worst 10-Best
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Lifestyle Questionnaire
Alcohol
Yes
No
If yes, Number of drinks per week
Tobacco
Yes
Cigarettes
Cigars
No
Illicit drug use
Yes
No
If yes, Explain
SYMPTOMS OF LOW TESTOSTERONE LEVELS
Decreased concentration
Yes
No
Difficulty learning new things
Yes
No
Memory loss
Yes
No
Moodiness
Yes
No
Depression
Yes
No
Increasing fatigue
Yes
No
Decreasing energy
Yes
No
Daytime sleepiness
Yes
No
Poor sleep habits
Yes
No
Decreased sex drive
Yes
No
I have had testosterone checked previously
Yes
No
I have used testosterone previously
Yes
No
Submit
Should be Empty: