MALE HORMONE QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential.

Please review our policies on making recommendations in the "Getting Started section located in the Resources tab on our website.

Name:

First NameLast Name

Date of Birth:

MonthDayYear

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address:

example@example.com

Height (in):

Weight (lbs):

Home:

Format: (000) 000-0000.

Mobile:

Format: (000) 000-0000.

ALLERGIES TO MEDICATIONS OR FOODS (DRUG/FOOD NAME & REACTION EXPERIENCED)

Do you have prescription drug insurance?

Insurance Company:

Insurance ID#:

Rx Group #:

Rx Bin #:

Rx PCN:

Doctor's Name:

Doctor's Phone:

Format: (000) 000-0000.

WHAT ARE YOUR MAIN REASONS FOR SEEKING CARE?

ARE YOU TAKING HORMONES? IF SO WHAT IS YOUR REGIMEN?

LIST ANY PREVIOUS HORMONE THERAPY YOU HAVE TRIED

LIST YOUR PRESCRIBED DRUGS AND OVER-THE-COUNTER DRUGS, SUCH AS VITAMINS, NUTRITIONAL OR NATURAL PRODUCTS YOU ARE CURRENTLY TAKING

SURGERY AND MEDICAL HISTORY All questions contained in this questionnaire are optional and will be kept strictly confidential.

HAVE YOU HAD ANY OF THE FOLLOWING SURGERIES?

CHECK ANY OF THE FOLLOWING CONDITIONS YOU HAVE HAD PREVIOUSLY OR CURRENTLY

IS THERE A FAMILY HISTORY OF..?