• Health Questionnaire

    If there are questions you prefer not to answer or are unsure about, feel free to leave them blank.
  •  -
  • Date of Birth*
     - -
  • Residence status

  • Health Information and History

  • Are you currently taking testosterone therapy?*
  • Have you had your Total Testosterone level checked in the last 12 months?
  • List here
  • Have you ever been diagnosed with any of the following:*

  • Please indicate if you have had any of the following in the past year, or of significance in the past.

  • Muskuloskeletal
  • Skin
  • Cardiovascular System
  • Neurological
  • Respiratory
  • Endocrine System
  • Mental/Emotional Health
  • Urinary System
  • Immune System

  • Health Assessment and Medical Information

  • IMPORTANT: Do you have any allergies to nut, seed, plant oils? (e.g., peanut, caster, cottonseed)*

  • Lifestyle Habits

  • How often do you exercise?
    Rows
  • Do you consume alcohol?
  • Average number of units per week (2 units are roughly equivalent to a medium glass of wine or a pint of standard strength beer or lager)
    Rows
  • Do you smoke tobacco?
  • Average number of cigarettes/day (currently or in the past)
    Rows

  • Home Environment

  • Sleep, Energy, and Stress Levels

  •
  • On average, how many hours of sleep do you get?
  • Do you have difficulty falling asleep?
  • Do you have difficulty staying asleep?
  • Do you nap during the day?
  • Do you have any plans to father children in the near future?
  • Optional - Check any that apply to you:

  • Men's Health

  • Are you sexually active?
  • Do you experience painful or difficult urination?
  • Should be Empty: