Men's Medical History & Symptoms

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Today's Date First Name Middle Name Last Name Street Address 1 Street Address 2 City State and Zip Phone E-mail Date of Birth Age Height Weight Occupation (determine stress factor) Drug Allergies If Any
Seasonal Allergies
None
Mild
Moderate
Severe
Tobacco
Yes
No
If so how many Pks?
Alcohol Consumption
Yes
No
If so what amount used per week?
Carbonate Beverages
Yes
No
How many per week? Current Medications Conditions or Diagnosis Exercise Times Per Week
Increased Urinary Urge
None
Mild
Moderate
Severe
Prostate Problems
None
Mild
Moderate
Severe
Decreased Erections
None
Mild
Moderate
Severe
Difficulty Concentrating
None
Mild
Moderate
Severe
Increased Forgetfulness
None
Mild
Moderate
Severe
Foggy Thinking
None
Mild
Moderate
Severe
Tearful
None
Mild
Moderate
Severe
Depressed
None
Mild
Moderate
Severe
Mood Swings
None
Mild
Moderate
Severe
Fluid Retention-Bloating
None
Mild
Moderate
Severe
Stress
None
Mild
Moderate
Severe
Anxious
None
Mild
Moderate
Severe
Irritable
None
Mild
Moderate
Severe
Nervous
None
Mild
Moderate
Severe
Decrease Mental Sharpness
None
Mild
Moderate
Severe
Morning Fatigue
None
Mild
Moderate
Severe
Afternoon Fatigue
None
Mild
Moderate
Severe
Evening Fatigue
None
Mild
Moderate
Severe
Excessive Worry
None
Mild
Moderate
Severe
Difficulty Falling Asleep
None
Mild
Moderate
Severe
Difficulty Staying Asleep
None
Mild
Moderate
Severe
Decreased Stamina
None
Mild
Moderate
Severe
Diminished Motivation
None
Mild
Moderate
Severe
Fibromyalgia
None
Mild
Moderate
Severe
Ringing in Ears
None
Mild
Moderate
Severe
Allergies
None
Mild
Moderate
Severe
Headaches/Migraines
None
Mild
Moderate
Severe
Dizzy Spells
None
Mild
Moderate
Severe
Sugar Cravings /Carb Cravings
None
Mild
Moderate
Severe
Craving Food, Alcohol, Tobacco or Other
None
Mild
Moderate
Severe
Poor Impulse Control
None
Mild
Moderate
Severe
Obsessive Behavior (OCD)
None
Mild
Moderate
Severe
Addictive Behavior
None
Mild
Moderate
Severe
Constipation
None
Mild
Moderate
Severe
Goiter
None
Mild
Moderate
Severe
Cold Body Temperature
None
Mild
Moderate
Severe
Hoarseness
None
Mild
Moderate
Severe
Hair Dry or Brittle
None
Mild
Moderate
Severe
Nails Breaking or Brittle
None
Mild
Moderate
Severe
Slow Pulse Rate
None
Mild
Moderate
Severe
Rapid Heartbeat
None
Mild
Moderate
Severe
Heart Fluttering/Palpitations
None
Mild
Moderate
Severe
Incontinence
None
Mild
Moderate
Severe
Hot Flashes
None
Mild
Moderate
Severe
Night Sweats
None
Mild
Moderate
Severe
Infertility Concerns
None
Mild
Moderate
Severe
Acne
None
Mild
Moderate
Severe
Scalp Hair Loss
None
Mild
Moderate
Severe
Weight Gain Hips
None
Mild
Moderate
Severe
Weight Gain Waist
None
Mild
Moderate
Severe
High Cholesterol
None
Mild
Moderate
Severe
Elevate Triglycerides
None
Mild
Moderate
Severe
Decreased Libido
None
Mild
Moderate
Severe
Decreased Muscle Size
None
Mild
Moderate
Severe
Decreased Flexibility
None
Mild
Moderate
Severe
Burned Out Feeling
None
Mild
Moderate
Severe
Sore Muscles
None
Mild
Moderate
Severe
Increased Joint Pain
None
Mild
Moderate
Severe
Neck or Back Pain
None
Mild
Moderate
Severe
Bone Loss
None
Mild
Moderate
Severe
Thinning Skin
None
Mild
Moderate
Severe
Rapid Aging
None
Mild
Moderate
Severe
Aches and Pains
None
Mild
Moderate
Severe
Irritable Bowel Syndrome
None
Mild
Moderate
Severe
Decreased Urine Flow
None
Mild
Moderate
Severe
Primary Care Physician Address 1 Address 2 Phone Fax Phone Number City, Zip
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