Men’s Health Profile Form
Patient Information
Name Invalid Input
Your E-mail address (*) Invalid Input
Date Invalid Input
Address
Invalid Input
Phone Invalid Input
Date Of Birth Invalid Input
Height Invalid Input
Weight Invalid Input
Medical & Social History: Please check the following that apply to you.
Invalid Input
Others: Invalid Input
Medication History: List all prescription and non-prescription medications that you are taking. (Include vitamins, herbals and supplements.)
Invalid Input
Drug Allergies:
Invalid Input
Circle Yes or No to the following questions. If yes, indicate if Mild, Moderate or Severe.
1. Do you feel more fatigued and/or tired than usual? Invalid Input
If yes Invalid Input
2. Have you noticed a decrease in your muscle mass? Invalid Input
If yes Invalid Input
3. Have you experienced a loss in muscle strength? Invalid Input
If yes Invalid Input
4. Have you experienced an increase in joint and/or muscle pains? Invalid Input
If yes Invalid Input
5. Have you noticed an increase in your waist size? Invalid Input
If yes Invalid Input
6. Do you have trouble losing weight? Invalid Input
If yes Invalid Input
7. Have you experienced a loss in height? Invalid Input
If yes Invalid Input
8. Do you have a decrease in your sex drive? Invalid Input
If yes Invalid Input
9.Have you experienced difficulty in establishing and/or maintaining full erections? Invalid Input
If yes Invalid Input
10. Do you have a decrease in spontaneous early morning erections? Invalid Input
If yes Invalid Input
11. Have you experienced changes in your usual sleep pattern? Invalid Input
If yes Invalid Input
12. Do you feel a decrease in your mental sharpness? Invalid Input
If yes Invalid Input
13. Have you had trouble concentrating? Invalid Input
If yes Invalid Input
14. Do you experience less enjoyment in personal interests and hobbies? Invalid Input
If yes Invalid Input
15. I am Invalid Input
years old
I feel Invalid Input
years old