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Online Medical Forms
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Online Medical Forms

Please fill out the form below as completely and accurately as possible as all the information is important in determining effective strategies for your testosterone replacement therapy program.

    Patient Information 1/11
  • How did you hear about us?*:
  • Title:
    Ms.
    Mrs.
    Dr.
  • First Name*:
  • Middle Name:
  • Last Name*:
  • DOB*:
  • Age:
  • Height:
  • Weight:
  • Marital Status:
    Single
    Married
    Divorced
    Separated
    Widowed
  • Home Phone:
  • Cell Phone*:
  • Work Phone:
  • Email Address*:
  • Street Address:
  • Apt / PO Box:
  • City:
  • State:
  • Postal Code:
  • Occupation:
  • Employer:
  • Employer Phone:
  • Referred By:
    In Case of Emergency 2/11
  • Name of local friend or relative (not living at same address):
  • Relationship to Patient:
  • Home Phone:
  • Work Phone:
  • Street:
  • City, State, Zip:
    Allergies 3/11
  • Please List any Allergies:
  • t
  • t
    Personal History 4/11
  • Primary Physician:
  • Last Visit:
  • Office Phone:
  • Fax:
  • List any significant findings on the exam:
  • Was a prostate exam performed?
    Yes
    No
  • Describe your general health:
    Excellent
    Good
    Fair
    Poor
    Widowed
  • Have you ever been diagnosed with any of the following?
  • Diagnosed Disease History
    Yes
    No
    Diagnosed Disease History
    Yes
    No
  • Head Trauma:
    Cancer of any type
  • Heart disease or any heart related issues
    HIV or related disease
  • High blood pressure
    Immune deficiency of any type
  • Strokes
    Skin disorders
  • Poor Circulation
    Muscular or bone disorders
  • Edema or Swelling
    Arthritis or autoimmune disorders
  • High Cholesterol
    Disorders of the nervous system
  • Hormonal imbalance of any type
    Seizure disorder
  • Blood disorders or disease of any type
    Psychiatric disorders
  • Sleep Apnea
    Psychiatric Hospitalizations
  • Lung disorders
    Depression
  • Breast cancer
    Vision disorders
  • Digestive disorders
    Hearing disorders
  • Liver disorders
    Upper respiratory, sinus disorders
  • Hepatitis of any type
    Excessive snoring
  • Diabetes
    Previous history of steroid use
  • Kidney disorders
    Previous history of hormone therapy
  • Bladder disorders
    Contagious condition
  • Prostate cancer
    Illnesses contracted while abroad
  • Prostate enlargement
    Life threatening conditions
  • Testicular or genital problems
    Any disorders not mentioned above: (fill in)
  • Physical defect or deformity
  • Please feel free to comment on any areas of concern with the above or your medical history:
    Lifestyle 5/11
  • Have you ever been diagnosed with any of the following?
  • Diagnosed Disease History
    Yes
    No
    Explain
  • Do you smoke? If yes, how often
  • Do you drink? If yes, how often?
  • Do you chew tobacco? If yes, how often?
  • Do you have chemical dependency? If yes, describe
  • Do you exercise? If yes, often
  • Do you have trouble sleeping?
  • Do you have any sexual performance issues?
  • Additional Information
    General Information 6/11
  • Do any of the following apply?
  • Diagnosed Disease History
    Yes
    No
    Explain
  • Have you noticed a decrease in your sex drive?
  • Have you noticed a decrease in energy levels?
  • Do you feel weaker or have less stamina?
  • Do you feel tired all the time?
  • Have you noticed decreased work performance?
  • Are you more lethargic after dinner?
  • Are you experiencing vaginal dryness?
  • Are you prone to sadness or anger?
  • Has your height diminished?
  • Are you suffering from less vitality?
  • Additional Information
    Medication 7/11
  • Are you currently taking any medications? If so, list each medication, dosage, and frequency below.
  • Additional Information
    Surgical History 8/11
  • List any past surgeries you may have had.
  • Procedure
    Date
  • Procedure
    Date
  • Procedure
    Date
  • Procedure
    Date
  • Additional Information
    Hospitalization 9/11
  • Were you ever hospitalized for any reason.
  • Reason
    Date
  • Reason
    Date
  • Reason
    Date
  • Reason
    Date
  • Additional Information
    Family History Part I 10/11
  • Do any of the following conditions run in your family?
  • Conditions
    Yes
    No
    Conditions
    Yes
    No
  • Heart Disease or heart related issue
    Blood / clotting disorders
  • High blood pressure
    Diabetes
  • High cholesterol
    Cancer of any form
  • Digestive disorder
    Nervous system disorders
  • Kidney problems
    Psychiatric disorder
  • Lung problems
    Arthritis
  • Auto-immune disorders
    Hepatitis
  • If you answered Yes to any of the above, use this space to explain.
    Family History Part II 11/11
  • Do any of the following conditions run in your family?
  • Father
    Living Age
    General Health
    Medical Issues
    Age
    Cause of Death
  • Mother
    Living Age
    General Health
    Medical Issues
    Age
    Cause of Death
  • Sibling
    Living Age
    General Health
    Medical Issues
    Age
    Cause of Death
  • Sibling
    Living Age
    General Health
    Medical Issues
    Age
    Cause of Death

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