Male Health
Male Health History Questionnaire

GENERAL INFORMATION

Name Today's Date
Age Date of Birth Height Weight Occupation

COMPLAINTS/CONCERNS

Please list your chief symptoms in order of decreasing severity, starting with the worst one. Please note how long each symptoms has been present.

Problem Onset Frequency Severity
1. e.g. Headaches January 2009 3 times per week Mild / moderate / severe
2
3
4
5
6
7

ALLERGIES

Medication/Supplement/Food Reaction

DENTAL HISTORY

Do you currently have any amalgam, silver, metal, and/or gold fillings? YesNo if yes, how many?
If yes, please list which kinds.
How long have you had these fillings?
If you do not have any fillings in your mouth, have you had any fillings removed in the last 12 months? YesNo
Have you had any dental work done in the last 12 months? YesNo

MEDICATIONS & SUPPLEMENTS

Medications: Please list any medications that you are currently taking or have taken in the last month, including antibiotics, non-prescription drugs, and prescription drugs.

Medication Name Dosage

Supplements: List all vitamins, minerals and other nutritional supplements that you are currently taking..

Supplement Name/Brand Dosage

Have your medications or supplements ever caused you unusual side effects or problems?

YesNo If yes, please describe.

SLEEP/REST

Average number of hours you sleep >10 8-10 6-8 <6
Do you have trouble falling asleep? YesNo
Do you get a second wind at night? YesNo
Do you feel rested upon awakening? YesNo
Do you have problems with insomnia? YesNo
Do you snore? YesNo
Do you use sleeping aids? YesNo Expailn

LIFESTYLE INDICATORS

TOBACCO HISTORY

Currently using tobacco? YesNo How many years? Packs per day:
If yes, what type? Cigarette Smokeless Cigar Pipe Patch/Gum
Previous smoking: How many years? Packs per day:
Are you exposed to 2nd hand smoke? If yes, please explain:

ALCOHOL INTAKE

How many drinks currently per week? 1 drink = 5 ounces wine, 12 oz. beer, 1.5 ounces spirits
None 1-3 4-6 7-10 >10
Previous alcohol intake? YesMildModerate High

CAFFEINE INTAKE

How many cups of coffee per day? None 1-3 4-6 7-10 >10
How many cans of soda per day? None 1-3 4-6 7-10 >10
Is the soda you drink, diet soda? YesNo

PREGNANCY HISTORY(Check box if yes and provide number of)

SYMPTOMS

SYMPTOMS Mild Moderate Severe Additional Comments
Body/joint aches
Weight gain
Weight loss
Elevated blood pressure
Elevated cholesterol
Digestive problems
Head hair loss
Dry skin/thinning skin
Constant hunger
Sweet cravings
Caffeine cravings
Salt cravings
Anger/Aggression
Irritability
Low mood/Depression
Concentration problems
Foggy thinking
Increased fatigue
Lowered Libido
Erectile Dysfunction
Frequent need to urinate
Pain with urination
Bone loss/osteoporosis
Low blood sugar
Other

MISCELLANEOUS

Have you had a vasectomy? YesNo When?
Have you had a reverse vasectomy? YesNo When?
Have you experienced symptoms related to the vasectomy? YesNo Explain
Do you have a history of prostate problems? YesNo Explain
Date of last Prostate Exam
Most recent PSA results Date
How often do you exercise? Never Rarely Sometimes Regularly
Other information for us to know:

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