Men’s Health History Questionnaire

    Email*

    Full name*

    Date of birth (m/d/y)*

    Home address (include City, State, Zip)*

    Preferred phone number*

    Primary Care Physician (Name & Number)

    Local pharmacy (Name & Number)*

    Personal Health History

    Reason for your visit*

    Medical history (include medical diagnoses, previous surgeries, & hospitalizations)

    Have you been diagnosed with HIV and if so, date of diagnosis*

    Currently prescribed medications (with dosing) & supplements

    Do you have any food/medication allergies and if so, please describe*

    Lifestyle History

    Do you exercise and if so, how often*

    Briefly describe your eating habits (ex. breakfast, lunch, dinner, snacking, intermittent fasting, etc.):

    Briefly describe daily water, soda, & coffee consumption:

    How often do you drink alcohol per week*?

    How often do you smoke/vape tobacco or nicotine per week*?

    How often do you smoke/consume THC per week*?

    Are you sexually active*?

    If yes, are you currently family planning*

    Any discomfort with intercourse and if so, please describe*

    Family Health History

    Is your father alive and if so, what is his age and medical history*

    If deceased, at what age and reason for death?

    Is your mother alive and if so, what is her age and medical history*

    If deceased, at what age and reason for death?

    If you have siblings, do they have any health conditions:

    If you have grandparents, do they have any health conditions:

    Mental Health History

    Please rate your daily stress level*

    If 7 or greater, please describe:

    Mental Health Questions*






    ADAM Questionnaire

    The Androgen Deficiency in Aging Males (ADAM) Questionnaire has been shown to be highly effective for screening patients with potential testosterone deficiency. Marking “Yes” to questions 1 or 7, or any 3 questions in total, suggests the presence of testosterone deficiency.

    10 QUESTIONS*











    Men’s Urinary History*

    How often do you get up to urinate during the night?








    Date of last prostate/rectal exam if applicable:

    Name/Contact information of Urologist if applicable:

    General Hormone Deficiency Questionnaire*




























    Other Symptoms Worth Noting

    Check areas where you are currently experiencing symptoms and list them below:

    If yes, please list here:

    Please indicate which medical services
    you may be interested in:

    Menu of Services

    (*Required Fields)
    Protected by Recaptcha. Privacy & Terms