MALE HORMONES

Todays Date
Name
E-mail Address: *
Birth Date
Age
Address
City
State
Zip Code
Home Phone
Mobile Phone
Gender
Height
Weight
Do You Use Tobacco?
Do You Use Alcohol
Do You Use Caffeine?
Doctors Name
Doctors Address
Doctors Phone Number
Allergies (Please Check All That ApplyPenicillin
Morphine
Dye allergies
Pet Allergies
Codeine
Aspirin
Nitrate Allergy
Seasonal Allergies
Sulfa Drugs
Food Allergies
No Known Allergies
Other
Please Describe the Allergic Reaction you Experienced and When it Occured
Over The Counter (OTC) Issues: Please check all products that you use occasionally or regularly. Check all that applyAspirin
Acetaminophen (Tylenol)
Ibuprofen (Motrin)
Naproxen (Aleve)
Ketoprofen (Orudis KT)
Cough Suppressants (Robitussin DM, others)
Combination Products (Cough & Cold Relievers, Triaminic DM, Nyquil, Other)
Antidiarrheals (Immodium, Pepto Bismol, Kaopectate, Other)
Laxatives/Stool Softeners (Doxidan, Correctol, Others)
Antihistamine Products (Chlor-Trimeton, Others)
Decongestant Products (Sudafed, Others)
Sleep Aids (Excedrin PC, Unisom, Sominex, Nytol, Others)
Diet Aids/Weight Loss Products (Dexatril, Others)
Antacids (Maalox, Mylanta, Tums, Others)
Acid Blockers (Tagamet HB, Pepcid C, Zantac 75, Prilosec OTC, Others)
Others
Diet: Please list your intake on a typical day
Medical Conditions/Diseases: Please check all that apply to youHeart Disease
High Cholesterol or lipids
High Blood Pressure
Depression
Ulcers: Stomach or Esophagus
Headaches/Migraines
Prostate Problems
Lung Condition (Asthma, Emphysema, COPD)
Blood Clotting Problems
Diabetes
Arthritis or Joint Problems
Seizure Disorder (Epilepsy)
Thyroid Disease (Overactive or Underactive Thyroid)
Eye Disease (Glaucoma, etc.)
Other
Current Prescription Medications
Preferred Dosage Forms
List Androgens Previously Taken
Bone Size
Body TypeAndrogenic
Do You Have a Family History of the Following: Please check all that applyProstate Cancer
Heart Disease
Osteoporosis
Have You Had Any of the Following Tests Performed? Check all that apply and please note the last date of each testPSA
Yes Within the Last Year
No
Date of Last Doctor Visit and Type of Doctor Last Seen
How Did You Arrive at the Decision to Consider Natural Androgen Replacement Therapy?
What are Your Goals with Taking Natural Androgen Replacement?

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