Male Hormone Patient Information

Personal Data

 
Wilmington, NC
Goldsboro, NC

Primary Care Physician

Present Symptoms

Past Medical History

Social History

Please remember that this information is strictly confidential and will be used only to address you symptoms and/or complaints.

 
 
 

Family History

Please list ALL illness(heart disease, stroke, diabetes, hypertension, cancer (breast, cervical, skin, prostate, lung, blood), etc. If a member is deceased, please list age of death and cause if known.

Medications

Please list ALL prescription medications. Include ALL over the counter medications, supplements, and vitamins.

Allergies

Urological History

 
Lung
Breast
Colon
Prostate
Skin
Lymphoma
Leukemia

Hormone Therapy History

Present Symptoms

Check which of these symptoms are troublesome and have persisted over time:
Increased Facial Hair
Increased Body Hair
Acne
Oily Skin
Nervous
Irritable
Anxious
Breast Cancer
Ovarian Cysts
Elevated Triglycerides
Sleep Disturbances
Low Libido
Vaginal Dryness
Fatigue
Aches/Pains
Memory Lapses
Foggy Thinking
Urinary Incontinence
Depressed
Anxious
Bone Loss
Sleep Disturbances
Apathy/Decreased Passion for Life
Decreased Muscle Mass
Heart Palpitations/Arrhythmia
Headaches
Fibromyalgia
Irritable
Thinning Skin
Heat Intolerance
Irritable
Heart Palpitations/Arrhythmia
Weight Loss
Tremors/Shakiness
Diarrhea
Nervousness/Anxious/Panic Attacks
Insomnia
Difficulty Conceiving/Infertility
Cold Intolerance
Constipation
Fatigue/Weakness
Unexplained Weight Gain
Inability to Lose Weight
Cold Body Temperature
Lack of Motivation
Voice has become hoarse
Aches/Pains
Hair Loss
Muscle Weakness
Muscle Cramps
Stress
Coarse Dry Skin
Sleep Disturbances
Bone Loss
Fatigue
Weight Gain – Waist
Loss of muscle mass
Thinning Skin
Elevated Triglycerides
Breast Cancer
Irritable
Anxious
Memory Lapses
Heart Palpitations
Headaches
Stress
Cold Body Temperature
Sugar Cravings
Low Libido
Hair Loss
Increased Facial Hair
Increased Body Hair
Acne
Nervous
Fatigue
Sugar Cravings
Allergies
Chemical Sensitivity
Stress
Cold Body Temperature
Irritable
Arthritis
Heart Palpitations
Aches/Pains
 

 

*Individual results may vary.