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    Patient Information 1/11
  • How did you hear about us?*:
  • Location*:
  • Title:
  • Marital Status:
  • First Name*:
  • Last Name*:
  • DOB*:
  • Age:
  • Height:
  • Weight:
  • Home Phone:
  • Cell Phone*:
  • Work Phone:
  • Email Address*:
  • Street Address:
  • Apt / PO Box:
  • City:
  • State:
  • Postal Code:
  • Occupation:
  • Employer:
  • Employer Phone:
  • Referred By:
    In Case of Emergency 2/11
  • Name of local friend or relative (not living at same address):
  • Relationship to Patient:
  • Home Phone:
  • Work Phone:
  • Street:
  • City, State, Zip:
    Allergies 3/11
  • Please List any Allergies:
    Personal History 4/11
  • Primary Physician:
  • Last Visit:
  • Office Phone:
  • Fax:
  • List any significant findings on the exam:
  • Was a prostate exam performed?
    Yes
    No
  • Describe your general health:
    Excellent
    Good
    Fair
    Poor
    Widowed
    • Have you ever been diagnosed with any of the following?
    • Diagnosed Disease History
      Yes
      No
      Head Trauma:
      Heart disease or any heart related issues
      High blood pressure
      Strokes
      Poor Circulation
      Edema or Swelling
      High Cholesterol
      Hormonal imbalance of any type
      Blood disorders or disease of any type
      Sleep Apnea
      Lung disorders
      Breast cancer
      Digestive disorders
      Liver disorders
      Hepatitis of any type
      Diabetes
      Kidney disorders
      Bladder disorders
      Prostate cancer
      Prostate enlargement
      Testicular or genital problems
      Physical defect or deformity
    • Diagnosed Disease History
      Yes
      No
      Cancer of any type
      HIV or related disease
      Immune deficiency of any type
      Skin disorders
      Muscular or bone disorders
      Arthritis or autoimmune disorders
      Disorders of the nervous system
      Seizure disorder
      Psychiatric disorders
      Psychiatric Hospitalizations
      Depression
      Vision disorders
      Hearing disorders
      Upper respiratory, sinus disorders
      Excessive snoring
      Previous history of steroid use
      Previous history of hormone therapy
      Contagious condition
      Illnesses contracted while abroad
      Life threatening conditions
      Any disorders not mentioned above: (fill in)
  • Please feel free to comment on any areas of concern with the above or your medical history:
    Lifestyle 5/11
  • Have you ever been diagnosed with any of the following?
  • Diagnosed Disease History
  • Do you smoke? If yes, how often
    Yes
    No
  • Do you drink? If yes, how often?
    Yes
    No
  • Do you chew tobacco? If yes, how often?
    Yes
    No
  • Do you have chemical dependency? If yes, describe
    Yes
    No
  • Do you exercise? If yes, often
    Yes
    No
  • Do you have trouble sleeping?
    Yes
    No
  • Do you have any sexual performance issues?
    Yes
    No
  • Additional Information
    General Information 6/11
  • Do any of the following apply?
  • Diagnosed Disease History
  • Have you noticed a decrease in your sex drive?
    Yes
    No
  • Have you noticed a decrease in energy levels?
    Yes
    No
  • Do you feel weaker or have less stamina?
    Yes
    No
  • Do you feel tired all the time?
    Yes
    No
  • Have you noticed decreased work performance?
    Yes
    No
  • Are you more lethargic after dinner?
    Yes
    No
  • Are your erections less hard?
    Yes
    No
  • Are you prone to sadness or anger?
    Yes
    No
  • Has your height diminished?
    Yes
    No
  • Are you suffering from less vitality?
    Yes
    No
  • Additional Information
    Medication 7/11
  • Are you currently taking any medications? If so, list each medication, dosage, and frequency below.
  • Additional Information
    Surgical History 8/11
  • List any past surgeries you may have had.
  • Procedure
    Date
  • Procedure
    Date
  • Procedure
    Date
  • Procedure
    Date
  • Additional Information
    Hospitalization 9/11
  • Were you ever hospitalized for any reason.
  • Reason
    Date
  • Reason
    Date
  • Reason
    Date
  • Reason
    Date
  • Additional Information
    Family History Part I 10/11
  • Do any of the following conditions run in your family?
  • Heart Disease or heart related issue
    Yes
    No
  • Blood / clotting disorders
    Yes
    no
  • High blood pressure
    Yes
    No
  • Diabetes
    Yes
    No
  • High cholesterol
    Yes
    No
  • Cancer of any form
    Yes
    No
  • Digestive disorder
    Yes
    No
  • Nervous system disorders
    Yes
    No
  • Kidney problems
    Yes
    No
  • Psychiatric disorder
    Yes
    No
  • Lung problems
    Yes
    No
  • Arthritis
    Yes
    No
  • Auto-immune disorders
    Yes
    No
  • Hepatitis
    Yes
    No
  • If you answered Yes to any of the above, use this space to explain.
    Family History Part II 11/11
  • Do any of the following conditions run in your family?
  • Father
  • Mother
  • Sibling
  • Sibling


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