Page 1 of 4 Name: __________________________________________________ Occupation: ___________________________ Marital Status: Single Married Divorced Number of Children: __________________ Date of Birth:____________________ Age:_____________ Height:________________ Weight:_______________ Please mark "Yes" or "No" for the following behaviors as they apply to you: Yes No Cigarettes (_____ packs per day for ______ years) Cigars Chewing Tobacco Alcohol (Frequency: _____Daily _____Weekly _____Occasionally _____Binge) Coffee (_____ cups/day _____Regular _____Decaf) Colas (______ glasses/day _____Regular _____Diet _____Caffeine Free) Stress level on a scale of 1 – 10: _________ What is your desired goal or areas of concern? Date of last: Colonoscopy: ____________________ PSA: ____________________ Bone Density: ____________________ Rectal Exam: ____________________ Medical and Family History Yes No Yes No Binge Eating Other Testicular Problems Compulsive Eating Vasectomy Eating Disorder Impotence Night Eating Inability to Ejaculate Prostate Problems Lack of Sexual Desire Prostate Surgery Decrease of Stamina Currently on a Specific Diet * Testicular Inflammation * If on specific diet, number of meals per day ______ Describe: ___________________________________________ Patient Medical History - Testosterone Replacement Visit
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Patient Medical History - Testosterone Replacement Visitforeveryounghw.com/.../2017/02/Patient-Medical-History-Testosteron… · Other Testicular Problems . Compulsive Eating : Vasectomy
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Signs and Symptoms Mild Moderate Severe NA Comments
Decreased lean muscle mass Muscle soreness/weakness Body/joint aches Weight loss Weight gain Low blood sugar Craving sweets (carbs) Caffeine/stimulant cravings Salt cravings Constant hunger Elevated cholesterol Elevated blood pressure Digestive problems Head hair loss Body hair loss Dry skin/thinning skin Decreased morning erections Lowered libido Erectile dysfunction Pain with ejaculation Frequent need to urinate Pain with urination Blood in urine Bone loss/osteoporosis Uncontrollable thirst Large volume urine Increased perspiration