Patient Medical History - Testosterone Replacement...

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Name: __________________________________________________ Occupation: ___________________________

Marital Status: Single Married Divorced Number of Children: __________________

Date of Birth:____________________ Age:_____________ Height:________________ Weight:_______________

Please mark "Yes" or "No" for the following behaviors as they apply to you: Yes No

Cigarettes (_____ packs per day for ______ years)

Cigars

Chewing Tobacco

Alcohol (Frequency: _____Daily _____Weekly _____Occasionally _____Binge)

Coffee (_____ cups/day _____Regular _____Decaf)

Colas (______ glasses/day _____Regular _____Diet _____Caffeine Free)

Stress level on a scale of 1 – 10: _________

What is your desired goal or areas of concern?

Date of last:

Colonoscopy: ____________________ PSA: ____________________

Bone Density: ____________________ Rectal Exam: ____________________

Medical and Family History Yes No Yes No

Binge Eating Other Testicular Problems

Compulsive Eating Vasectomy

Eating Disorder Impotence

Night Eating Inability to Ejaculate

Prostate Problems Lack of Sexual Desire

Prostate Surgery Decrease of Stamina

Currently on a Specific Diet * Testicular Inflammation

* If on specific diet, number of meals per day ______ Describe: ___________________________________________

Patient Medical History - Testosterone Replacement Visit

PATIENT MEDICAL HISTORY

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Myself Mother Father Grandparent Sibling NA

Cancer Diabetes Heart Disease Arthritis Liver Disease Cholesterol Endocrine Problems High Blood Pressure Neuro Disease Lung Disease Kidney Disease Stomach Disease Bowel Disease Blood Clots Weight Problems Osteoporosis Anemia Alcoholism Drug Use Prostate Cancer Prostate Infections Enlarged Prostate

Please list all operations and surgical procedures, including dates:

Serious injuries, accidents, or serious illnesses:


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Allergies to medications or foods:

List all your current medications, including prescriptions, over the counter, and supplements: Name Dose Times/Day

Hormone Deficiency Questionnaire Signs and Symptoms Mild Moderate Severe NA Comments

Depression Irritability Anxiety Anger/Aggression Pessimism Decreasing interest in activities and relationships

Decreased initiative Decreased productivity Concentration problems Memory problems Foggy thinking Increased fatigue Decrease in strength/stamina Decreased athletic performance


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Signs and Symptoms Mild Moderate Severe NA Comments

Decreased lean muscle mass Muscle soreness/weakness Body/joint aches Weight loss Weight gain Low blood sugar Craving sweets (carbs) Caffeine/stimulant cravings Salt cravings Constant hunger Elevated cholesterol Elevated blood pressure Digestive problems Head hair loss Body hair loss Dry skin/thinning skin Decreased morning erections Lowered libido Erectile dysfunction Pain with ejaculation Frequent need to urinate Pain with urination Blood in urine Bone loss/osteoporosis Uncontrollable thirst Large volume urine Increased perspiration

Patient Signature: _________________________________________________________ Date: ________________

Patient Medical History - Testosterone Replacement...

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