MEDICAL QUESTIONNAIRE

Are any of the following diseases in your immediate family?
Have either of your parents had a heart attack or a cardiac stent before age 60?
Have you smoked any cigarettes in the past month?
Have you ever used any recreational drugs?
How much alcohol do you drink in a week? One drink = 4 oz wine, 12 oz beer, 1 oz liquor.

REVIEW OF SYMPTOMS - CHECK ANY SYMPTOMS YOU HAVE

GENERAL
Endocrine
SKIN
NEUROLOGIC
SCALP/HEAD
EYES
EARS
NOSE
MOUTH
ALLERGY
LUNGS
HEART
GI/Abdomen
Urology
Blood/Lymph
Psychology
Men only: Do you have a decrease in libido (sex drive)?
Men only: Do you have a lack of energy?
Men only: Do you have a decrease in strength and /or endurance?
Men only: Have you lost height?
Men only: Have you noticed a decreased “enjoyment of life”?
Men only: Are you sad and /or grumpy?
Men only: Are your erections less strong?
Men only: Have you noted a recent deterioration in your ability to play sports?
Men only: Are you falling asleep after dinner?
Men only: Has there been a recent deterioration in your work performance?

RECENT DIAGNOSTIC TESTS

Thanks for submitting!