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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
Weight Loss
Weight Gain
Fatigue
Joint Pain
Cancer
Personal History of Cancer
Prostate Cancer
Autoimmune Disorder
Cardiovascular
Heart Failure
Heart Attack
Heart Murmur
Vascular Disease
Blood Clots
Edema
High Blood Pressure
Rapid Heart Beat
High Cholesterol
Congestive Heart Failure
Respiratory
Sleep Apnea
Shortness of Breath
Asthma
Bronchitis
Pneumonia
COPD
Gastrointestinal
Nausea
Vomiting
Diarrhea
Heart Burn
Constipation
Genitourinary
Overactive Bladder
Painful Urination
Weak Urine Flow
Blood in Urine
On/Off Urine Flow
Enlarged Prostate (BPH)
Kidney Damage
Muscle Skeletal
Muscle Tendon Ligament Tear
Back Pain
Knee Pain
Shoulder Pain
Muscle Loss
Arthritis
Psychiatric
Depression
Anxiety
Insomnia
Medications
Drug Name
Drug Name
Drug Name
Allergies:
Surgeries
Year
Surgery/Reason
Year
Surgery/Reason
Health Habit and Personal Safety
Exercise
None
Mild
Occasional vigorous exercise
Regular vigorous exercise
Have you used Testosterone (prescribed or otherwise) or any other anabolic steroids in the past?
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
Tobacco
Vaping
Cigarettes
Cigars
No
Energy Drinks
Yes
No
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
Less morning wood?
Yes
No
Reduced muscle mass?
Yes
No
Submit
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