EmailMe Form - Patient Intake Form For Men

Patient Intake Form For Men

Thank you in advance for taking the time to fill this out. This information helps me to provide the safest and most effective care for you.

Name *

First Last

Date of Birth *

MM / DD / YYYY

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Phone Number *

### - ### - ####

Email Address *

Ontario Health Card Number

Relationship status

Occupation

If you are self-employed, please detail your activity so that I can understand what occupation may suggest about your health. Is it sedentary, primarily administrative in nature, or are there any occupational current or prior hazards that might affect your health? Please describe.

	Height (Ft/In)	Weight (Ibs)	Waist Measurement (In)	Last blood pressure, if known
Physical Metrics

Primary Care Provider - Name/Telephone *

Other Health Care Providers - Name/Telephone

Allergies

Alcohol Use (past, current, drinks per week)

Smoking
If you smoke please include for how many years? How many packs per day?

Please describe any other substance use history, current and past

What are your current health concerns? *

Please list in priority, note how long you have had these health concerns, what treatments you have tried for these concerns, and the results of the treatments? If you have consulted other healthcare providers for these concerns please include the recommendations and outcome of any treatments advised.

Please note what treatment(s) you are interested in.

Please note your current medical diagnosis, or any current health concerns that you are seeking investigation for. *

Please list any current medications including supplements. *

For each medication please list why you are taking this and how long.

Please describe your current diet. Please describe the diet that you have felt best on in the past, if this is different.

Please describe your digestive health, any reflux, diarrhea, constipation.

Please describe your exercise patterns.

Please describe your sleep and whether you have difficulty falling asleep, staying asleep, or waking up rested. If you have sleep problems, have you had sleep study? Also, have you tried anything to help your sleep and has it worked at all?

Please note your past medical history. *

Please describe your family history, include all cancers, cardiovascular disease, blood pressure or cholesterol problems. With cancers and cardiovascular problems, please note how old person was when problem was noted.

Do you have any thoughts about biologically fathering a child in your future? *

Please note any questions you have about BHRT

Please describe your family history, include all cancers, cardiovascular disease, blood pressure or cholesterol problems. With cancers and cardiovascular problems, please note how old person was when problem was noted.

Are you up to date on all recommended cancer screenings? *

Please be advised that NP Melissa does not provide ongoing primary care and that it Is essential for you to remain up to date on recommended screenings, and to promptly report to Melissa any new or concerning symptoms.

Going forward, I agree to keep my cancer screenings updated and advise NP Melissa of any abnormal findings. *

Yes

Men’s age-related symptoms rating score

Please note each of the 17 symptoms on a scale of 1-5
1 none 2 mild 3 moderate 4 severe 5 extremely severe

*

	1 (NONE)	2 (MILD)	3 (MODERATE)	4 (SEVERE)	5 (EXTREMELY SEVERE)
Decline in your feeling of general well-being
Joint pain and muscle ache
Excessive sweating
Sleep problems (difficulty falling asleep, staying asleep, sleeping through the night, waking up early and tired, poor sleep or sleeplessness)
Increased need for sleep, often feeling tired
Irritability
Nervousness
Anxiety
Physical exhaustion, lacking vitality
Decrease in muscle strength
Depressed mood
Feeling that you have passed your peak
Feeling burnt out
Decrease in beard growth
Decrease in ability/frequency to perform sexually
Decrease in the number or quality of morning erections
Decrease in sexual desire/libido

Do you have any other major symptoms? If yes, please describe.

Do you consent to communication via text, WhatsApp, and email? If you are uncomfortable or would like certain restrictions with any of these methods of communication, please advise of your preferences.

Yes

No

Other Preference

If you are seeking medical assistance for weight optimization, please provide further info on strategies you have used before, how successful or unsuccessful they have been.

Please send copies of recent labs or relevant diagnostic imaging.