First Name*

Last Name*

Street

City

State

Zip

Phone*

Sex*
MaleFemale

Date of Birth

Age

Height

Weight

Email*

Do you drink alcohol?
YesNo

If yes, how much?

Do you smoke?
YesNo

If yes, how much?

Please list all Medications, Hormones & Supplements

Medication Allergies

Food Allergies

Who referred you to us?

Please list your health care provider

Date of Last Visit/Checkup

ANDROPAUSE CHECKLIST

Section I

Check All That Apply

Adult MumpsProstate Operation or InflammationVasectomyOrchitis or Other Testicular ProblemsPersistent Urinary Infections

Section II

Check Box That Best Describes Your Symptoms

Fatigue, tiredness or loss of energyDepression, low or negative moodIrritability, anger, or bad temperAnxiety or nervousnessLoss of memory or concentrationRelationship problem with partnerLoss of sex drive or Libido Erection or potency problemsDry skin on face or handsExcessive sweating, day or nightBackache, stiffness, joint or muscle painFrequent use of alcohol, past or presentLoss of physical stamina Feeling over-stressedLoss of early morning erectionIncreased fat distribution in chest area or hipsFeeling burned out, loss of motivationDecrease in muscle massIncrease in waist size – weight gain, especially in mid section

First Name*

Last Name*

Street

City

State

Zip

Phone*

Sex*
MaleFemale

Date of Birth

Age*

Height

Weight

Email*

Please list all Medications, Hormones & Supplements

Medication Allergies

Primary Doctor's Name

Primary Doctor's Address

Primary Doctor's Phone

Date of Last Checkup

Papsmear Date

Mammogram Date

Last Menstrual Period

Hysterectomy
NoYes

Surgery Date

Ovaries Removed
NoYes

Surgery Date

Bilateral Tubal Ligation
NoYes

Surgery Date

History of Endometriosis
NoYes

History of Fibroids
NoYes

History of Polycystic Ovary Syndrome (PCOS)?

History of Abnormal Papsmear?

History of Female Organ Cancer?

History of Blood Clots (DVT, Pulmonary Embolism?)

How did you hear about us?