Male Hormone Registration FormPersonal DataFirst Name *Middle NameLast Name *Email Address *Home PhoneWork/Cell PhoneStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeDate of Birth *HeightWeightEmployerEmergency ContactEmergency PhoneMarital StatusMarriedWidowedSeparatedDivorcedSingleOtherPrimary Care PhysicianNamePhone/FaxStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodePresent SymptomsPlease briefly describe your symptoms.What do you feel is the most important factor to your present symptoms?Past Medical HistoryPlease list dates and diagnoses, illnesses, accidents (1 per line).Please list dates and surgeries (1 per line).Social HistoryPlease remember that this information is strictly confidential and will be used only to address you symptoms and/or complaints.Do you smoke cigarettes now? If yes, how many packs per day?Have you smoked in the past? If yes, how many total years have you smoked?Do you drink alcohol? If yes, how many drinks and what type of alcohol (beer, wine, spirits, etc.) do you have in an average week?Family HistoryPlease 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.MotherFatherBrother(s)Sister(s)ChildrenSpouseMedicationsPlease list ALL prescription medications. Include ALL over the counter medications, supplements, and vitamins.MedicationsAllergiesAre you allergic to any MEDICATIONS (Prescription or OTC)?Urological HistoryLast prostate examPhysicianPhysician's phoneHave you ever had an abnormal prostate exam? If yes, what was the abnormality and what follow up did you have?Have you ever had an elevated PSA? If yes, what was the abnormality and what follow up did you have?Have you ever had a prostate biopsy.LungBreastColonProstateSkinLymphomaLeukemiaHave you ever had an elevated PSA? If yes, what was the abnormality and what follow up did you have?Other cancerDo you have burning when you urinate?Do you have urgency when you urinate?Do you have difficulty urinating?Have you ever had kidney problems?Hormone Therapy HistoryHave you been treated with any hormone replacement therapy? If yes, please give approximate periods of treatment.Present SymptomsAndrogen ExcessIncreased Facial HairIncreased Body HairAcneNervousIrritableAnxiousBreast CancerOvarian CystsElevated TriglyceridesSleep DisturbancesCheck which of these symptoms are troublesome and have persisted over time:Androgen DeficiencyLow LibidoVaginal DrynessFatigueAches/PainsMemory LapsesFoggy ThinkingUrinary IncontinenceDepressedAnxiousBone LossSleep DisturbancesApathy/Decreased Passion for LifeDecreased Muscle MassHeart Palpitations/ArrhythmiaHeadachesFibromyalgiaIrritableThinning SkinThyroid ExcessHeat IntoleranceIrritableHeart Palpitations/ArrhythmiaWeight LossTremors/ShakinessDiarrheaNervousness/Anxious/Panic AttacksInsomniaDifficulty Conceiving/InfertilityThyroid DeficiencyCold IntoleranceConstipationFatigue/WeaknessUnexplained Weight GainInability to Lose WeightCold Body TemperatureLack of MotivationAches/PainsHair LossMuscle WeaknessMuscle CrampsStressCoarse Dry SkinCortisol ExcessSleep DisturbancesBone LossFatigueWeight Gain – WaistLoss of muscle massThinning SkinElevated TriglyceridesBreast CancerIrritableAnxiousMemory LapsesHeart PalpitationsHeadachesStressCold Body TemperatureSugar CravingsLow LibidoHair LossIncreased Facial HairIncreased Body HairAcneNervousCortisol DeficiencyFatigueSugar CravingsAllergiesChemical SensitivityStressCold Body TemperatureIrritableArthritisHeart PalpitationsAches/PainsSend Form
