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Patient Questionnaire (Male)

Name:
Today’s Date:
Date of Birth:
Age:
Occupation:
Home Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work:
Email Address:
How did you hear about us?
Patient Name:
Event:
Practitioner Name:
Pharmacy Name:
Social Media Type:
TV Station:
Radio Station:
Web Keyword Searched:
Signage
Print Ad seen in:
In Case of Emergency Contact:
Relationship:
Cell Phone:
Home Phone:
Work:
Pharmacy Name:
Phone:
Address:
Primary Care Physician’s Name:
Phone:
Address:
May we share your clinical information with your PCP/Gyn?
Yes
No
MEDICAL HISTORY
Weight:
Have you ever had any issues with anesthesia?
Yes
No
Do you smoke?
Yes
No
Quit
How much?
How often?
Age started?
Do you drink alcohol?
Yes
No
Quit
How much?
How often?
Age started?
Any known drug allergies:
Yes
No
If yes please explain:
Current Medications and dosage:
Nutritional/Vitamin Supplements:
Current Hormone Replacement Therapy:
Past HRT:
Surgeries, list all and when:
Other Pertinent Information:
Do you have a family history of?
Heart Disease
Cancer
Diabetes
Other:
High blood pressure
High cholesterol
Heart disease
Stroke
Heart attack
Blood clot or pulmonary emboli
Hemochromatosis
Depression / anxiety
Psychiatric disorder
Diabetes
Thyroid disease
Arthritis
Trouble passing urine or take Flomax or Avodart
Chronic liver disease (hepatitis, fatty liver, cirrhosis)
Prostate enlargement
Elevated PSA
Other:
Testicular or prostate
Year:
Other:
Year:

I understand that if I begin testosterone replacement with any testosterone treatment, including testosterone pellets, I will produce less testosterone from my testicles. And if I stop testosterone replacement I may experience a temporary decrease in my testosterone production. Testosterone pellets should be completely out of your system in 12 months.

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DATE