NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVER S LICENSE NUMBER: STATE: ADDRESS:

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Transcription:

NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVER S LICENSE NUMBER: STATE: EMAIL ADDRESS: MARITAL STATUS: ( ) SINGLE ( ) MARRIED ( ) DIVORCED ( ) WIDOWED ( ) SEPERATED ( ) UNDISCLOSED PATIENT S EMPLOYER: WORK #: BUSINESS ADDRESS: CITY: STATE: ZIP: EMPLOYER: WORK #: EMERGENCY CONTACT: PHONE: WHOM MAY WE THANK FOR REFERRING YOU: RELATIONSHIP TO PATIENT: DATE OF BIRTH: ADDRESS: CITY: STATE: CONTACT #: ( ) CELL ( ) HOME PATIENT SIGNATURE: DATE:

Occupation: Primary Care Doctor (PCP): Phone number: Pharmacy Number: Date of last physical exam: Personal Health History Please circle all that apply: General Diabetes Personal History of High Cholesterol Family History of Unwanted Weight Loss Autoimmune Disorder Cardiovascular Heart Failure Heart Attack Heart Murmur Vascular Disease Blood Clots Edema Congestive Heart Hypertension Irregular Heartbeat Failure Respiratory Sleep Apnea Shortness of Breath Asthma/ COPD Bronchitis Pneumonia Allergies Gastrointestina l Lactose Intolerance Gall Bladder Gall Stones Genitourinary Chronic Diarrhea Prostate Painful Urination Enlarged Prostate Chronic Constipation Prostate In Family Decreased Urinary Force Blood in Urine Overactive Bladder ON/OFF Urine Flow Kidney/Bladder History Infection Kidney/Bladder Liver Any other Psychiatric History of Depression Personality Disorder Any other

List your prescribed drugs and any over-the-counter drugs, such as vitamins and inhalers. Please make sure to include any anti-anxiety or antidepressant medications. Allergies: No Known Allergies or List Allergies and Reaction Surgeries: Year Surgery/Reason Year Surgery/Reason HEALTH HABITS AND PERSONAL SAFETY Exercise: Sedentary (No exercise) Mild exercise Occasional vigorous exercise Regular vigorous exercise Describe type of exercise and frequency (resistance training, cardiovascular, number of times per week)

Rate your quality of sleep: 1-Worst 10-Best 1 2 3 4 5 6 7 8 9 10 Lifestyle Questionnaire Alcohol: Yes Number of drinks per week: No Tobacco: Yes Cigarettes Cigars Chewing How many/much: No Illicit drug use: Yes Explain No Vitals Blood Pressure Pulse Respiratory Rate Weight Height SYMPTOMS OF LOW TESTOSTERONE LEVELS Daytime sleepiness Yes No Decreased concentration Yes No Decreased energy Yes No Decreasing muscle mass Yes No Decreasing muscle strength Yes No Depression Yes No Difficulty learning things Yes No Diminished sex drive Yes No Erectile dysfunction Yes No Frequent joint/muscle pains Yes No Height decrease Yes No Increasing fatigue Yes No Memory loss Yes No

Moodiness Yes No Poor sleeping habits Yes No Trouble losing weight Yes No I have had testosterone checked previously Yes No I have used testosterone (prescribed or otherwise) or any other anabolic steroids in the past **Please be completely truthful with your response - it is critical in order to diagnose and prescribe correctly ** Yes No If yes, date(s): Type: Usage: I hereby also declare that I will not be attending or starting any military basic/advanced individual training (AIT) school while I am a patient of Axis Rejuvenation, LLC. Patient Name (Print) DOB: Signature: Date:

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