BHRT Analysis Form Male

First and Last Name (*)	Invalid Input
Birthdate (*)	Invalid Input
Age (*)	Invalid Input
Date	Invalid Input
Address (*)	Invalid Input
City, State, Zip Code (*)	Invalid Input
E-mail Address (*)	Invalid Input
Home Phone (*)	Invalid Input
Work Phone	Invalid Input
Fax	Invalid Input
Occupation	Invalid Input
What is your greatest need or problem? (list the most important; then list other issues in order of importance)	Invalid Input
Drug allergies	Invalid Input
Allergies to food, pollens, environment, etc:	Invalid Input
Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them:	Invalid Input
Indicate any herbal products you have taken: (Evening Primrose Oil-EPO, Chaste Tre Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc). Other:	Invalid Input
Names of ALL vitamins, supplements, non-prescription medicines, or other OTC products that you are currently using	Invalid Input
If you are currently taking medication for a thyroid condition, which one and what dose	Invalid Input
Have you ever had a bone density scan?	YesNo Invalid Input
If yes, when	Invalid Input
BMI Results for Adults Over 35	19-26.9 Recommended27-29.9 Overweight30-39.9 Obese40(+) Morbidly Obese Invalid Input
Waist Circumference:	Invalid Input
Hip Circumference	Invalid Input
Waist:Hip Ratio	Invalid Input
Medical & Social History: Please check the following that apply to you	High Blood Pressure High Cholesterol Cardiovascular Disease Diabetes Mellitus Osteoporosis Benign Prostatic Hyperplasia Tobacco Use Asthma/COPD Alcohol Use Erectile Dysfunction Insomnia Malnutrition Depression Cancer Other Invalid Input
Other	Please specify in here... Invalid Input
Medication History: List all prescription and non prescription medications that you are taking (Include vitamins, herbals and supplements).	Invalid Input
Do you feel more fatigued/tired than usual?	YesNo Invalid Input
If yes, check	MildModerateSevere Invalid Input
Have you noticed a decrease in your muscle mass?	YesNo Invalid Input
If yes, check	MildModerateSevere Invalid Input
Have you experienced a loss in muscle strength?	YesNo Invalid Input
If yes, check	MildModerateSevere Invalid Input
Have you experienced an increase in joint and/or muscle pain?	YesNo Invalid Input
If yes, check	Mild ModerateSevere Invalid Input
Have you noticed an increase in your waist size?	YesNo Invalid Input
If yes, check	MildModerateSevere Invalid Input
Do you have trouble losing weight?	YesNo Invalid Input
If yes, check	MildModerateSevere Invalid Input
Do you have a decrease in your sex drive?	YesNo Invalid Input
Have you expereanced a loss in heights	YesNo Invalid Input
If yes, check	MildModerateSevere Invalid Input
Have you experienced difficulty in establishing and/or maintaining full erections?	YesNo Invalid Input
If yes, check	MildModerateSevere Invalid Input
Do you have a decrease in spontaneous early morning erections?	YesNo Invalid Input
If yes, check	MildModerateSevere Invalid Input
Have you experienced changes in your usual sleep pattern?	YesNo Invalid Input
Do you feel a decrease in your mental sharpness?	YesNo Invalid Input
If yes, check	MildModerateSevere Invalid Input
Have you had trouble concentrating?	YesNo Invalid Input
Do you experience less enjoyment in personal interests and hobbies?	YesNo Invalid Input
If yes, check	MildModerateSevere Invalid Input
If yes, check	MildModerateSevere Invalid Input
I feel xx years old	Invalid Input
I am xxx years old	Invalid Input
Click to submit your form