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Medical Forms

Patient Information 1/11

In Case of Emergency 2/11

Allergies 3/11

Personal History 4/11

Have you ever been diagnosed with any of the following?
Diagnosed Disease History
Yes
No
Diagnosed Disease History
Yes
No
Head Trauma:
Cancer of any type
Heart disease or any heart related issues
HIV or related disease
High blood pressure
Immune deficiency of any type
Strokes
Skin disorders
Poor Circulation
Muscular or bone disorders
Edema or Swelling
Arthritis or autoimmune disorders
High Cholesterol
Disorders of the nervous system
Hormonal imbalance of any type
Seizure disorder
Blood disorders or disease of any type
Psychiatric disorders
Sleep Apnea
Psychiatric Hospitalizations
Lung disorders
Depression
Breast cancer
Vision disorders
Digestive disorders
Hearing disorders
Liver disorders
Upper respiratory, sinus disorders
Hepatitis of any type
Excessive snoring
Diabetes
Previous history of steroid use
Kidney disorders
Previous history of hormone therapy
Bladder disorders
Contagious condition
Prostate cancer
Illnesses contracted while abroad
Prostate enlargement
Life threatening conditions
Testicular or genital problems
Any disorders not mentioned above: (fill in)
Physical defect or deformity
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
Yes
No
Explain
Do you smoke? If yes, how often?
Do you drink? If yes, how often?
Do you chew tobacco? If yes, how often?
Do you have chemical dependency? If yes, describe
Do you exercise? If yes, often
Do you have trouble sleeping?
Do you have any sexual performance issues?

General Information 6/11

Do any of the following apply?
Diagnosed Disease History
Yes
No
Explain
Have you noticed a decrease in your sex drive?
Have you noticed a decrease in energy levels?
Do you feel weaker or have less stamina?
Do you feel tired all the time?
Have you noticed decreased work performance?
Are you more lethargic after dinner?
Are your erections less hard?
Are you prone to sadness or anger?
Has your height diminished?
Are you suffering from less vitality?

Medication 7/11

Are you currently taking any medications? If so, list each medication, dosage, and frequency below.

Surgical History 8/11

List any past surgeries you may have had.

Hospitalization 9/11

Were you ever hospitalized for any reason.

Family History Part I 10/11

Do any of the following conditions run in your family?
Conditions
Yes
No
Conditions
Yes
No
Heart Disease or heart related issue
Blood / clotting disorders
High blood pressure
Diabetes
High cholesterol
Cancer of any form
Digestive disorder
Nervous system disorders
Kidney problems
Psychiatric disorder
Lung problems
Arthritis
Auto-immune disorders
Hepatitis

Family History Part II 11/11

Do any of the following conditions run in your family?