Male New Patient Questionnaire
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- Myron Newton
- 5 years ago
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1 Patient Demographics First Name: Middle: Last Name: Home Phone: Cell Phone: Address: SSN: City: State: Zip: Age: Date of Birth: Referred by: Occupation: Primary Care Physician: Employer: Emergency Contact Information Name: Primary Phone: Relationship: Secondary Phone: Reason for Visit: Height Weight Blood Pressure (office use only) Allergies (List all allergies - Food, Drug, Other) Page 1 of 5
2 Current Medications (List all current medications) Drug Dose How Often? Supplements (List all current supplements) Supplement Dose How Often? Symptoms of Hormonal Deficiencies (check all that apply) Lack Or Decreased Sex Drive ED: Erectile Dysfunction Decreased or No Ejaculation Loss of Morning Erections Insomnia Memory Loss/Trouble Thinking Loss of Motivation New Migraine Headaches Decreased Muscle Mass & Strength Joint Aches/Arthritis Lack of Energy -Fatigue Constipation Thinning Eyebrows Poor Immunity Exhausted In The Morning Can't Fall Asleep Poor Balance Poor Coordination Increased Belly Fat Ringing in Ears Thinning Hair Depression New Anxiety Attacks Male Breast Development Cold All The Time Generalized Swelling Brittle Nails Irritable Low Blood Sugar Stay Awake For Days Ache All Over Page 2 of 5
3 Exercise History (Check all that apply) I Don't Exercise I Have A Physical Job I Exercise Daily For Minutes I Exercise 3 Times/Week For 50 Min or More I Am A Long Distance Runner I Lift Weights Times A Week Normal Activity is What I Consider Exercise Previous Testosterone Replacement (Check all that apply) I Have Used Pellet T Before I Have Used T Gel Before I Have Used T Shots Before Other: Past Surgeries (List year of surgery) Habits (Check all that apply) Surgery Lap Band Surgery or Obesity Surgery Open Heart Surgery Joint Replacement Cancer Surgery Vasectomy Smoking Cigarettes Or Cigars I Drink More Than 10 Drinks of Alcohol/Week I am a Recovering Alcoholic I Use or Have Used Marijuana In Past I Use or Have Used Cocaine I Use or Have Used Anabolic Steroids I Use or Have Used Growth Hormone Family History (Check all that apply) Prostate Cancer Other Cancers Lung Cancer Breast Cancer (Female) Breast Cancer (Male) Obesity Heart Disease Heart Arrhythmias Thyroid Disease Arthritis Autoimmune Disease Diabetes Type I Diabetes Type II Hemochromatosis Preventative Medicine (Check all that apply) PCP Visit in Last Urologist Within Last Colonoscopy In Last 10 s Prostate exam in last year Page 3 of 5
4 Medical Illnesses (List year of Illness) Illness ADD, ADHD Addison's Disease Adrenal Fatigue Alcoholism, Aa, Drug Dependence Arthritis Blood Clot/Pulmonary Embolism BPH: Benign Prostatic Enlargement Cancer Depression/Anxiety Diabetes Type I Diabetes Type II Emphysema / Copd Fatty Liver Disease Glaucoma Heart Attack Hemochromatosis Hepatitis High Blood Pressure Illness HIV, AIDS Insulin Resistance Kidney Disease Manic Depression or Bipolar Disorder Multiple Sclerosis Narcolepsy Osteoporosis Past History Of Head Injuries Post Concussion Syndrome Prostate Cancer Restless Legs Schizophrenia Seizures or Epilepsy Sleep Apnea Stroke TB Testicular Cancer Leber s Optic Neuritis Played Contact Sports (Yes/No) Had a Concussion? (Yes/No) Social History (Check all that apply) I Have Completed My Family I Am Married or in Committed Relationship I am Sexually Active I Want to be Sexually Active I attest that all the information I give is true. Diet History (Check all that apply) I Eat Anything I Want I Don't Eat Much And Gain Weight Anyway I Have Gained Weight In My Abdomen I Eat A Balanced Diet 3 Times A Day I Eat 6 Small Meals A Day I Don't Eat Meat or Animal Products I Am Gluten Sensitive I Limit Carbohydrates I Eat Low Fat Diet High Protein Diet Other: Print Name: Signature: Date: Page 4 of 5
5 Communication Consent to Communicate Please indicate the ways you consent for to communicate with you Cell Phone Home Phone Work Phone Text Message Can contact (Yes/No) Can leave message (Yes/No) Do we have permission to speak with spouse/partner? Yes No Do we have permission to leave a message with spouse/partner? Yes No If yes, please list name(s) and relationship Print Name: Signature: Date: Page 5 of 5
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