EmailMeForm
MALE HEALTH HISTORY
NAME
First
Last
DATE
MM
/
DD
/
YYYY
HOME ADDRESS
Street Address
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
D.O.B.
MM
/
DD
/
YYYY
HOME
PHONE
###
-
###
-
####
WHY ARE YOU HERE
TODAY ?
PRIMARY CARE
PHYSICIAN
CURRENT MEDICATIONS
***INCLUDE NAME STRENGTH AND FREQUENCY***
MEDICATION
ALLERGIES
LATEX ALLERGY ?
YES
NO
EXERCISE
YES
NO
ACTIVITY
LEVEL
ACTIVE*
MODERATE*
VERY ACTIVATE
SUBSTANCE
USAGE
ALCOHOL
TOBACCO
CAFFEINE
STREET DRUGS
USE THE FOLLOWING FIELD TO UPLOAD ANY LAB OR OTHER RESULTS
****NECESSARY TO HELP US BETTER ANALYZE YOUR MEDICAL STATUS****
FILE UPLOAD
***YOU CAN UPLOAD ANY FORMER LAB RESULTS***
***************PERSONAL MEDICAL HISTORY************************
****************Symptoms that pertain directly to you*********************
HIGH
CHOLESTEROL
YES
NO
HEART
DISEASE
YES
NO
HIGH BLOOD
PRESSURE
YES
NO
DIABETES
YES
NO
THYROID
ISSUES
YES
NO
ASTHMA
YES
NO
BLOOD
DISORDER
YES
NO
CANCER
YES
NO
AIDS
YES
NO
KIDNEY/BLADDER
ISSUES
YES
NO
CHLAMYDIA
YES
NO
GONORRHEA
YES
NO
HERPES
YES
NO
SYPHYLLIS
YES
NO
HEPATITIS
YES
NO
BIRTH DEFECTS
YES
NO
PHYSICAL ABUSE
YES
NO
OTHER MEDICAL
ISSUES
DATE OF LAST
PROSTATE EXAM
***********************FAMILY HISTORY***************************
HIGH BLOOD
PRESSURE
YES
NO
DIABETES
YES
NO
HIGH
CHOLESTEROL
YES
NO
HEART
ATTACK
YES
NO
BLOOD DISORDER
YES
NO
CANCER
YES
NO
BIRTH
DEFECTS
YES
NO
PROSTATE
ENLARGEMENT
YES
NO
LOW LIBIDO
NONE
MILD
MODERATE
SEVERE
LOSS OF MUSCLE MASS
NONE
MILD
MODERATE
SEVERE
PROBLEMS URINATING
NONE
MILD
MODERATE
SEVERE
LOSS OF ENERGY
NONE
MILD
MODERATE
SEVERE
ERECTILE DYSFUNCTION
NONE
MILD
MODERATE
SEVERE
POOR WORKOUT REVOVERY
NONE
MILD
MODERATE
SEVERE
LETHARGY
NONE
MILD
MODERATE
SEVERE
MOOD SWINGS
NONE
MILD
MODERATE
SEVERE
CENTRALIZED WEIGHT GAIN
NONE
MILD
MODERATE
SEVERE
OTHER MEDICAL ISSUES
SURGICAL HISTORY
***********DATE/PROCEDURE/COPLICATIOS**********
REVIEWED BY
CLINIC
LOCATION
Crestview
Ft. Walton Beach
Tampa/Brandon
Pensacola
TYPING YOUR NAME HERE
IS A LEGAL AND BINDING
SIGNATURE THAT IMPLIES
A FULL UNDERSTANDING
OF THE ABOVE INFORMATION.
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