Medical Form

How did you hear about us?:OnlineWebsiteExisting PatientOther

First Name:

Last Name:

DOB:

Sex:MaleFemale

Age:

Height:

Weight:

Relationship Status:SingleMarriedDivorcedSeperatedWidowed

Home Phone:

Cell Phone:

Email:

Street:

Apt/PO:

City:

State:

Postal Code:

Occupation:

Employer:

Employer Phone:

Referred By:

Emergency Contact Name:

Relationship:

Home Phone:

Cell Phone:

Street:

City,State,Zip

List of Allergies

Primary Physician:

Date of Last Visit:

Office Phone:

Office Fax:

Any Significant Findings On The Exam?

Was a Prostate Exam Performed?YesNo

Have You Ever Been Diagnosed With Any Diseases?YesNo

If yes, Please Describe

Do you Smoke?:YesNo

Do you Drink?:YesNo

Do you Chew Tobacco?:YesNo

Do You Have Any Chemical Dependency?:YesNo

Do You Exercise?:YesNo

Do You Have Trouble Sleeping?:YesNo

Do You Have Any Sexual Performance Issues?:YesNo

Have You Noticed A Decrease In Your Sex Drive?:YesNo

Have You Noticed A Decrease In Energy Levels?:YesNo

Do You Feel Weaker Or Have Less Stamina?:YesNo

Do You Feel Tired All Day?: YesNo

Have You Noticed A Decrease In Work Performance?:YesNo

Are You More Lethargic After Dinner?: YesNo

Are Your Erections Less Hard?: YesNo

Are You Prone to Sadness or Anger?:YesNo

Has Your Height Diminished?: YesNo

Are You Suffering From Less Vitality?:YesNo

Are You Currently Taking Any Medications? If So, List Each Medication, Dosage, And Frequency Below.

List Any Past Surgeries You May Have Had.

Were You Ever Hospitalized For Any Reason?

Do Any Of The Following Conditions Run In Your Family? Heart DiseaseHigh Blood PressureHigh CholesterolDigestive disorderKidney ProblemsLung ProblemsAuto-Immune disordersBlood disordersDiabetesCancer of any formNervous system disordersPsychiatric disordersArthritisHepatitis

Select Family Members With Conditions Any AboveFatherSiblingMother