PAST HEALTH HISTORY:
Height
Do you feel panic attacks?
Yes
No
Do you feel anxious?
Yes
No
Gastrointestinal disease:
heart burn
gall bladder
gall stones
diarrhea
constipation
required
*
PLEASE ANSWER THE FOLLLOWING:
Problems staying asleep?
Yes
No
Date and time
12:00 AM
12:30 AM
1:00 AM
1:30 AM
2:00 AM
2:30 AM
3:00 AM
3:30 AM
4:00 AM
4:30 AM
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5:30 AM
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11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
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4:30 PM
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7:30 PM
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8:30 PM
9:00 PM
9:30 PM
10:00 PM
10:30 PM
11:00 PM
11:30 PM
Abdomen:
Crohn's disease
Hepatitis C
Nausea
Vomiting
Decreased appetite Constipation
Diarrhea
Rectal Bleeding
bowel dysfunction
bladder dysfunction
Any history of illegal steroid use, Past or Present?
Yes
No
Do you feel pain or burning with urination?
Yes
No
Do you have any problems emptying your bladder completely?
Yes
No
Exercise:
Sedentary (No exercise)
Mild exercise
Occasional exercise
Regular vigorous exercise
Problems falling asleep?
Yes
No
Do you have Diarrhea?
Yes
No
Depression?
Yes
No
Difficulty concentrating?
Yes
No
Do you drink alcohol?
Yes
No
Occasionally
Cardiovascular disease:
chest pain
heart failure
murmur
vascular disease
blood clots
fainting
lower extremity edema
Thank you for contacting us! If needed, you will hear back within 48-72 hours.
Any Constipation?
Yes
No
If yes, how many times per week?
Do you make/eat home cooked meals?
Yes
No
Organ system review- Do you have Any of the following?
SYMPTOMS OF LOW TESTOSTERONE LEVELS
MALE HEALTH HISTORY
Do you smoke cigarettes?
Yes
No
Former smoker
Do you have daytime fatigue?
Yes
No
Name:
*
ALLERGIES TO MEDICATION (Name the Drug and state the Reaction You Had)
What is your major symptom/problem?
*
Musculoskeletal:
neck injury
back pain
weakness
muscle
joint pain or stiffness
paralysis
limitation of movement
arthritis
fibromyalgia
muscle atrophy
muscle spasms
pain bending
pain lifting
GENERAL:
chills
fever
weight loss
night sweats
night pain
a. m. stiffness
rashes
puffyiness
poor appetite
Are you currently taking anticoagulants such as Aspirin, Warfarin or Coumadin?
Yes
No
Any recent fever, chills, rashes, unexplained weight loss, loss of appetite, night sweat, night pain?
Yes
No
Other:
Diabetes
High Blood Pressure
Cancer
Depression
Anxiety
High Cholesterol
Sleep Apnea
Pain
If yes, occupation:
Daytime Sleepiness?
Yes
No
How many hours do you sleep?
Decreasing sex drive?
Yes
No
Health Habits and Personal safety:
Neuro:
MS
Epilepsy
ALS
Alzheimer's
fainting
dizziness
numbness
tingling/burning
Tremors
Stroke
Seizures
Headaches
Address:
*
Poor Sleep Habits?
Yes
No
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WEIGHT LOSS FORM
MALE HORMONE CHECKLIST
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MALE HEALTH HISTORY
FEMALE HEALTH HISTORY
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Any problems reaching climax?
Yes
No
Date of Birth:
*
Do you depressed?
Yes
No
Erectile Dysfunction?
Yes
No
Cardio:
Chest pain
Murmurs
Cardiac disorder
High Blood Pressure
Angina
Abnormal EKG
Congestive Heart Failure
Heart Attack
Kidney Disorder
Arrhythmia
Any seizure history?
Yes
No
Head:
ear ringing
headaches
blurry vision
glaucoma
nasal fractures
tooth pain
jaw pain
vertigo
tongue pain
macular degeneration
Weight Gain?
Yes
No
Increasing Fatigue?
Yes
No
Do you have sleep issues?
Yes
No
Moodiness?
Yes
No
Weight:
Has the force of your urination decreased?
Yes
No
Do you eat fast food meals?
Yes
No
IRIE NATURAL CENTER FOR HEALTH
TELEMEDICINE AVAILABLE
TELEMEDICINE AVAILABLE
Have you had any kidney, bladder, or prostate infection within the last 12 months?
Yes
No
Are you taking sleeping pills?
Yes
No
Genitourinary disease:
overactive bladder
frequent urination
pain urination
difficult urination
prostate enlargement
BPH
kidney stones
Email:
*
Check here to receive email updates
Phone:
*
Do you feel beaning discharge from penis?
Yes
No
MEDICATIONS: (All medication including aspirin or vitamin supplements) DOSAGE, HOW OFTEN TAKEN?
Are you currently working?
Yes
No
Any difficulty achieving or sustaining erection or ejaculation?
Yes
No
Respiratory disease:
shortness of breath
asthma
bronchitis
pneumonia
allergies
hay fever
Male:
Prostate cancer
Testicular cancer
Low sex drive
weight gain
sexual dysfunction
fatigue
problems reaching climax
Decreased energy?
Yes
No
When was you last blood work?
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