Men’s Health History Questionnaire

    Section 1 of 10

    Men’s Health History Questionnaire

    All personal information will be kept confidential and HIPAA compliant.

    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) *

    Section 2 of 10

    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? *

    Section 3 of 10

    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?

    Section 4 of 10

    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:

    Section 5 of 10

    Mental Health History

    Please rate your daily stress level

    If 7 or greater, please describe:






    Section 6 of 10

    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.











    Section 7 of 10

    Men’s Urinary History









    Date of last prostate/rectal exam if applicable:

    Name/Contact information of Urologist if applicable:

    Section 8 of 10

    General Hormone Deficiency Questionnaire



























    Section 9 of 10

    Other Symptoms Worth Noting

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

    If yes, please list here:

    Section 10 of 10

    Please indicate which medical services
    you may be interested in:

    (*Required Fields)
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