• Miami Holistic Center

    MALE HEALTH HISTORY QUESTIONNAIRE

    To be completed before your initial consultation

     

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    For the most accurate evaluation, please complete the form below carefully and thoroughly. Your privacy will be strictly protected (see our Privacy Policy).  

    It should take you some time to complete this form properly so ensure you have at least one hour to dedicate to this important information gathering phase.  When you are finished please click on the "Submit" button at the bottom of the form.

    DO NOT CLICK SUBMIT UNTIL YOU ARE FINISHED AS YOU WILL LOOSE ALL ENTRIES AND WILL NEED TO START OVER.

     

    PATIENT INFORMATION

    Your Full Name:

    Age:
    Date of Birth:
    Weight:
    Height:
    Marital Status: single married divorced widowed
    Occupation:
    Email:
    Cell Phone:
    Home Address:
    City, State, Zip:
    Employed By:
    Employer's Address:
    Emergency Contact phone & Relationship:

    How did you hear about us:  

    If referred by a friend, who may we thank?

     

    MEDICAL HISTORY

    What is the reason for this visit?

    List medications you are currently taking:

    Any known Drug Allergies?

    List natural supplements, herbs, remedies, including athletic performance supplements you are currently taking:

    Do you or have you used hormone replacement therapy? Yes      No

    If so, what?   When and for how long?

    What dosage?

    Date of last physical exam:


    SIGNIFICANT ILLNESSES (PLEASE CHECK ALL THAT APPLY)


    Arthritis:

    Asthma:
    Autoimmune
    :
    AIDS:
    Cancer
    Diabetes:

    Gallstones:
    Heart Disease:

    Kidney stones:

    Rheumatic fever:

    Ruptured Appendix:
    Seizures:
    Thyroid Disease:
    Venereal Disease:
    Hepatitis:

    Hypertension:

    Connective tissue disorders

     

     

     

     

     

     

    LIFESTYLE INDICATORS:  < = less than      > = greater than

    Do you use any of the following?    

    Alcohol   None      <2 drinks/day    >2 drinks/day    stopped recently, when?     

    Coffee     None    <2 cups/day  >2 cups/day        stopped recently,     when?     

    Soda       None    <2 cans/day    >2 cans/day      stopped recently,     when?          

    Sweets/refined carbs  None  less than twice/day   more than twice/day    stopped recently

    Do you smoke cigarettes/cigars or use nicotine gum or other stimulants? Yes      No

    Amount

    How would you rate your stress level? (1 =Low, 10=Extreme)        

    How would you rate your stress handling? (1=Poor, 10=Excellent)                             

    How often do you exercise? never     rarely     sometimes      regularly     competitively

     

    1. Have you had a vasectomy? Yes   No If yes, When?

    2. Have you had a reverse vasectomy? Yes   No If yes, When?

    3. Have you experienced symptoms related to the vasectomy? Yes   No  If yes, Explain

    4. Do you have a history of prostate problems? Yes   No  If yes, Explain

    Date of last Prostate Exam

    Most recent PSA results    Date


    SLEEP HABITS

    How do you sleep? Well       Trouble falling asleep      Trouble staying asleep      Insomnia

                 If experiencing sleep problems, how long has this been happening?


    Do night sweats wake you up?     Yes   No      If yes, how often?

     

    Do you wake up tired?     Yes   No

    How long has this been happening?


    Is your room completely dark when you sleep at night? (no night light, street lamp, TV, etc.) Yes   No

    Do you get at least 30 minutes of outside daylight time, several days each week?Yes   No


     SlGNS & SYMPTOMS Mild Moderate Severe More Information
    Low mood/Depression
    Irritability
    Anxiety
    Anger
    Aggression
    Discouragement / Pessimism
    Decreased interest in activities / relationships
    Decreased initiative / motivation / drive
    Decreased productivity at work
    Concentration problems
    Memory problems
    Foggy thinking
    Increased fatigue
    Decrease in strength / stamina
    Decrease in athletic performance
    Decreased lean muscle mass
    Muscle soreness / weakness
    Body /Joint aches
    Weight loss
    Weight gain
    Increased fat on hips/breasts /thighs
    Low blood sugar / hypoglycemia
    Sweet cravings (carbs/chocolate)
    Caffeine/Stimulant cravings
    Salt cravings
    Constant hunger
    Elevated cholesterol
    Elevated blood pressure
    Digestive problems
    Head hair loss
    Need to shave less frequently
    Body hair loss
    Dry skin / thinning skin
    Decreased spontaneous morning erections
    Lowered Libido
    Erectile Dysfunction (ED)
    Pain with ejaculation
    Any other symptoms not listed above?

     

    Do you have other comments on your  health?

    Please scroll up to the top and double check what you have completed and correct any error before submission.

    Click on this Button to Submit information Securely to Dr. Moreira's Email
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