patient medical history - testosterone replacement...
TRANSCRIPT
Page 1 of 4
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
Page 2 of 4
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:
PATIENT MEDICAL HISTORY
Page 3 of 4
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
PATIENT MEDICAL HISTORY
Page 4 of 4
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: ________________