Medical HX Personal Information ADDRESS PHONE NUMBERS Others Medical History GENERAL Gender MaleFemale Primary Physician Information Others FAMILY HISTORY Does an immediate family member currently have or ever had any of the following? Cardiovascular disease (heart attack, stroke, coronary artery bypass) YesNoN/A Diabetes, thyroid or other Endocrine Disorder YesNoN/A Hypertension YesNoN/A High cholesterol/lipids YesNoN/A Prostate cancer YesNoN/A Other forms of cancer YesNoN/A Other illnesses YesNoN/A If yes for other illnesses, please list them here LIFESTYLE INFORMATION Do you smoke? YesNoN/A If Yes, how much do you smoke per day? Do you drink alcohol? YesNoN/A If Yes, how much do you drink per week? Do you take over the counter supplements? YesNoN/A If Yes, list Name and Quantity per day/week. Do you exercise regularly? YesNoN/A If Yes, please describe. Medical History Any known deficiency including minerals and electrolytes YesNoN/A Orthopedic or muscle disorder including fracture or joint disorders YesNoN/A Use of medications (if yes, list medications below) YesNoN/A Chemical Dependency YesNoN/A Blood disorders YesNoN/A Carpal Tunnel syndrome YesNoN/A Immune disorders YesNoN/A Heart disease including Atherosclerosis, Angina, Heart Failure, Heart Attack YesNoN/A Cancer YesNoN/A Lung disorder YesNoN/A Allergies to Medications YesNoN/A frequent upper respiratory infections YesNoN/A Edema / excess fluid retention YesNoN/A Poor wound healing YesNoN/A Emotional disorders / depression YesNoN/A Renal disease YesNoN/A Genital – Urinary disorder: YesNoN/A Hyperlipidemia YesNoN/A Hypertension YesNoN/A Neurological disorders YesNoN/A Thyroid, Diabetes or other endocrine disorder including insulin resistance YesNoN/A Arthritis YesNoN/A Bursitis YesNoN/A Rheumatism YesNoN/A Sports Injury(s) YesNoN/A Other illnesses YesNoN/A Explain the history of any above checked diseases: List all the medications you are taking. Please be specific (Name, dosage, etc.) or specify “none”: Prior history of steroids or other hormones? YesNoN/A If yes, list type of medication, strength, dosage used, and dates of use (month and year) to your best memory Type/Dose/Frequency: QUESTIONS FOR TREATMENT Do you currently have or have experienced any of the following symptoms? If Yes, please check and explain below: Increased lack of drive YesNoN/A Depression YesNoN/A Increasing fat deposits around the abdomen and/or thighs YesNoN/A Difficulty sleeping YesNoN/A Increasing mood swings YesNoN/A Increasing wrinkles YesNoN/A Progressive osteoporosis, decreasing bone density, or low trauma fractures YesNoN/A Headaches / Migraines YesNoN/A Increasingly stressed YesNoN/A Loss of concentration, sociability, activity YesNoN/A Hot flashes YesNoN/A Decreased desire and ability to exercise YesNoN/A Loss of interest in sex YesNoN/A Decreased energy or endurance YesNoN/A Muscle loss YesNoN/A Sore Muscles, joint pain(s) or swelling YesNoN/A Sagging, loose or thin skin YesNoN/A Thinning or loss of hair YesNoN/A Decreasing memory YesNoN/A Decreasing size of testicles YesNoN/A Decreasing muscle strength YesNoN/A Weight loss – Unexplained YesNoN/A Decreasing size of testicles YesNoN/A Cold or heat intolerance YesNoN/A Other YesNoN/A Please use this space to explain any additional information
