Male Hormone History Form

Male Hormone Consultation History
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Past Medical History
AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyNone of the above
Please describe any other medical problems or details of the above:
YesNo
List medication/s if applicable:
YesNoNot Sure
Social History
Do you use tobacco products?*
Do you use or do you have history of using illicit drugs?*
DailyWeeklyMonthlyOccasionallyNever
Urological History
Lung cancerBreast cancerProstate cancerColon cancerSkin cancerLymphomeLeukemiaNone of the above
Hormone Therapy History
YesNo
If yes, please explain:
Androgen Deficiency
Low libidoLack of energyDecreased muscle strengthLost heightDecreased enjoyment in lifeSad or grumpyMemory issuesConcentration issuesWeak erectionsDecreased ability to play sportsFalling asleep during the daySleep difficulty at nightDeterioration in work performanceHair loss
Adrenal Function - Cortisol Deficiency
FatigueSugar cravingsEnvironmental allergiesStressIrritabilityCold body temperatureHeart palpitationsAches and pain
Adrenal Function - Cortisol Excess
Sleep problemsFatigueBone lossWeight gainLoss of muscle massThinning of the skinHeart palpitationsStressLow libidoAcneNervousness / AnxietyIncreased body or facial hair
Thyroid Under Activity
Cold body temperatureConstipationWeight gainHair lossDry skinStressIrritabiliryLack of motivationMuscle crampsAches and pains
Thyroid Over Activity
Heat intoleranceWeight lossNervousnessAnxietyHoarseness of the voiceEye problemsLeg swellingDiarrheaTremorsShakinessInfertilityCoarse 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
Should be Empty:

Male Hormone Consultation History

Past Medical History

Social History

Urological History

Hormone Therapy History

Androgen Deficiency

Adrenal Function - Cortisol Deficiency

Adrenal Function - Cortisol Excess

Thyroid Under Activity

Thyroid Over Activity

General Questions