MALE HORMONE QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential.
CONTACT & PERSONAL INFORMATION
Please review our policies on making recommendations in the "Getting Started section located in the Resources tab on our website.
Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date Picker Icon
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address if not applicable please put N/A:
example@example.com
Height (in):
*
Weight (lbs):
*
PHONE NUMBER(S)
Home if not applicable please put N/A:
*
Mobile if not applicable please put N/A:
*
ALLERGIES TO MEDICATIONS OR FOODS (DRUG/FOOD NAME & REACTION EXPERIENCED) if not applicable please put N/A:
*
INSURANCE INFORMATION
Do you have prescription drug insurance?
*
Yes
No
Insurance Company:
*
Insurance ID#:
*
Rx Group #:
*
Rx Bin #:
*
Rx PCN:
*
Doctor's Name:
*
Doctor's Phone:
*
Format: (000) 000-0000.
Is the patient the primary cardholder, spouse, or dependent?
*
WHAT ARE YOUR MAIN REASONS FOR SEEKING CARE? if not applicable please put N/A:
*
ARE YOU TAKING HORMONES? IF SO WHAT IS YOUR REGIMEN? if not applicable please put N/A:
*
LIST ANY PREVIOUS HORMONE THERAPY YOU HAVE TRIED. if not applicable please put N/A:
*
LIST YOUR PRESCRIBED DRUGS AND OVER-THE-COUNTER DRUGS, SUCH AS VITAMINS, NUTRITIONAL OR NATURAL PRODUCTS YOU ARE CURRENTLY TAKING. if not applicable please put N/A:
*
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?
*
Radical Prostatectomy
Turp
None of the above
CHECK ANY OF THE FOLLOWING CONDITIONS YOU HAVE HAD PREVIOUSLY OR CURRENTLY
*
Thyroid disease
Fibromyalgia/autoimmune disease
Atherosclerosis
Osteoporosis
Low Sperm Count
Cancer
High Cholesterol
Heart Disease
High Blood Pressure
Prostate Problems
Sleep Apnea
None of the above
Other
IS THERE A FAMILY HISTORY OF..?
Thyroid disease
Low Sperm Count
High Blood Pressure
Prostate Problems
Atherosclerosis
High Cholesterol
None of the above
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DO YOU USE TOBACCO PRODUCTS?
*
Yes
No
IF YES, IS YOUR DOCTOR AWARE?
*
Yes
No
HOW OFTEN DO YOU USE TOBACCO PRODUCTS? if not applicable please put N/A:
*
IF YOU HAVE ANY QUESTIONS, PLEASE ASK THEM HERE. if not applicable please put N/A:
*
RATE THE FOLLOWING IF YOU HAVE EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS RECENTLY
*
Rows
O None
1 Mild
3 Moderate
4 Severe
Sleep disruption/Insomnia
Decreased libido (sex drive)
Weakness
Depression
Fatigue
Erectile Dysfunction
Slow wound healing
Reduced muscle mass
Irritability
Nervousness/anxiety
Mood Swings
Weight Gain
Short term memory loss
Other:
Submit
Should be Empty: