Male History & Screening Form

MALE HISTORY & SCREENING FORM

Name: ______DOB: ______DATE:______

General Information (Social History)

Family Physician and/or Primary Health Care Provider:

Doctor/Other______Phone ______

Address ______City ______

May I send a copy of your consultation to your physician or primary health care provider and consult with them as necessary?

YesNo

Marital Status:

Single Married/Partnered Divorced Widowed

Occupation:

Position ______Employer ______



Are you currently on any type of hormone replacement therapy? Or have you been on hormone replacement therapy in the past? Please describe.

Personal Medical History

Check those questions to which your answer is yes (leave others blank).

Heart disease (heart attack, CHF, etc)

Hypertension

High cholesterol

Prostate problems

Sleep apnea

Bladder problems

Blood clotting problems

Diabetes or abnormal blood-sugar tests

Headaches or migraine

Epilepsy or seizures

Stroke

Mental health problems (depression, bipolar, etc)

Anemia

Thyroid problems

Lung problems

Jaundice, liver or gall bladder problems

Liver problems

Other (please explain):
______

Answer the following:

List any prescription medications and doses you are now taking:
______

List any dietary supplements or vitamins you are now taking:
______

List any drug allergies:
______

Date of last complete physical examination: ______

______

List hospitalizations, including dates of and reasons for hospitalization:
______

Family Medical History

Have any of your blood relatives had any of the following (include grandparents, aunts and uncles, but exclude cousins, relatives by marriage and half-relatives)?

Check those to which the answer is yes (leave others blank).

Heart attacks under age 50

Strokes under age 50

High blood pressure

Elevated cholesterol

Diabetes

Blood clots

Heart operations

Obesity (20 or more pounds overweight)

Cancer

Please provide details:
______

Father:

AliveCurrent age ______

My father's general health is:

ExcellentGoodFairPoor

Medical Problems:______

DeceasedAge at death ______

Cause of death:______

Mother:

AliveCurrent age ______

My mother's general health is:

ExcellentGoodFairPoor

Medical problems:______

DeceasedAge at death ______

Cause of death: ______

Siblings:

Number of brothers ______Number of sisters ______Age range ______

Medical problems ______

Risk Factors

Smoking

Have you ever smoked cigarettes, cigars or a pipe?

YesNo

(If no, skip to next section)

If you did or now smoke cigarettes, how many per day? ______Age started ______

If you did or now smoke cigars, how many per day? ______Age started

If you did or now smoke a pipe, how many pipefuls a day? ______Age started ______

If you have stopped smoking, when was it? ______

Alcohol

Do you ever drink alcoholic beverages?

YesNo

If yes, what is your approximate intake of these beverages?

 0-1 per day  2-3 per day  >3 per day

At any time in the past, did you consider yourself to have an alcohol problem?

YesNo

Comments:
______

What are your goals with Bioidentical Hormone Replacement Therapy (BHRT)?

______

Please list any questions or concerns you have about BHRT:

______