Male Hormone Consultation History
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Past Medical History
Check the conditions that apply to your:
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
None of the above
Please describe any other medical problems or details of the above:
Are you currently taking any medication?
*
Yes
No
List medication/s if applicable:
Do you have any medication allergies?
*
Yes
No
Not Sure
Social History
Do you use tobacco products?
*
Please Select
Yes
No
Do you use or do you have history of using illicit drugs?
*
Please Select
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Urological History
Do you have any of the following?
Lung cancer
Breast cancer
Prostate cancer
Colon cancer
Skin cancer
Lymphome
Leukemia
None of the above
Hormone Therapy History
Have you ever received Hormone Replacement Therapy
Yes
No
If yes, please explain:
Androgen Deficiency
Please indicate any of the following symptoms that have bothered you lately:
Low libido
Lack of energy
Decreased muscle strength
Lost height
Decreased enjoyment in life
Sad or grumpy
Memory issues
Concentration issues
Weak erections
Decreased ability to play sports
Falling asleep during the day
Sleep difficulty at night
Deterioration in work performance
Hair loss
Adrenal Function - Cortisol Deficiency
Please indicate which of the following symptoms have been bothering you:
Fatigue
Sugar cravings
Environmental allergies
Stress
Irritability
Cold body temperature
Heart palpitations
Aches and pain
Adrenal Function - Cortisol Excess
Please indicate any of the following symptoms that have bothered you recently:
Sleep problems
Fatigue
Bone loss
Weight gain
Loss of muscle mass
Thinning of the skin
Heart palpitations
Stress
Low libido
Acne
Nervousness / Anxiety
Increased body or facial hair
Thyroid Under Activity
Pleas indicate if you have any of the following symptoms:
Cold body temperature
Constipation
Weight gain
Hair loss
Dry skin
Stress
Irritabiliry
Lack of motivation
Muscle cramps
Aches and pains
Thyroid Over Activity
Please indicate any of the following you are experiencing:
Heat intolerance
Weight loss
Nervousness
Anxiety
Hoarseness of the voice
Eye problems
Leg swelling
Diarrhea
Tremors
Shakiness
Infertility
Coarse dry skin
General Questions
What would you like to achieve by seeing the physician?
Any comments or things you would like me to address in our consultation?
Type a question
Submit
Should be Empty: