Male Hormone Questionnaire All questions contained in this questionnaire are strictly confidential. Question Title * 1. Contact Information Name Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Question Title * 2. Phone Number(s) Home Mobile Question Title * 3. Date of Birth Date of Birth Date Question Title * 4. Allergies to medications or Foods (Drug/Food name & reaction experienced) Question Title * 5. Height (in) Question Title * 6. Weight (lbs) Question Title * 7. Do you have prescription drug insurance? Yes No Question Title * 8. Insurance Company Question Title * 9. Insurance ID# Question Title * 10. Rx Group # Question Title * 11. Rx Bin # Question Title * 12. Doctor's Name Question Title * 13. Doctor's Phone Question Title * 14. What are your main reasons for seeking care? Question Title * 15. Are you taking hormones? If so what is your regimen? Question Title * 16. List any previous hormone therapy you have tried: Question Title * 17. List your prescribed drugs and over-the-counter drugs, such as vitamins, nutritional or natural products you are currently taking: SURGERY AND MEDICAL HISTORYAll questions contained in this questionnaire are optional and will be kept strictly confidential. Question Title * 18. Have you had any of the following surgeries? Radical Prostatectomy Turp Question Title * 19. Check any of the following conditions you have had previously or currently: Thyroid disease Low Sperm Count High Blood Pressure Heart Disease Fibromyalgia/autoimmune disease Cancer Prostate Problems Atherosclerosis High Cholesterol Sleep Apnea Osteoporosis Other Question Title * 20. Is there a family history of…? Thyroid Disease Prostate Problems Low Sperm Count Atherosclerosis High Blood Pressure High Cholesterol Question Title * 21. Do you use tobacco products? Yes No Question Title * 22. If you smoke is your doctor aware? Yes No Question Title * 23. If you have any questions please ask them here: Question Title * 24. RATE THE FOLLOWING IF YOU HAVE EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS RECENTLY. 0 None 1 Mild 3 Moderate 4 Severe Sleep disruption/Insomnia Sleep disruption/Insomnia 0 None Sleep disruption/Insomnia 1 Mild Sleep disruption/Insomnia 3 Moderate Sleep disruption/Insomnia 4 Severe Decreased libido (sex drive) Decreased libido (sex drive) 0 None Decreased libido (sex drive) 1 Mild Decreased libido (sex drive) 3 Moderate Decreased libido (sex drive) 4 Severe Weakness Weakness 0 None Weakness 1 Mild Weakness 3 Moderate Weakness 4 Severe Depression Depression 0 None Depression 1 Mild Depression 3 Moderate Depression 4 Severe Fatigue Fatigue 0 None Fatigue 1 Mild Fatigue 3 Moderate Fatigue 4 Severe Erectile Dysfunction Erectile Dysfunction 0 None Erectile Dysfunction 1 Mild Erectile Dysfunction 3 Moderate Erectile Dysfunction 4 Severe Slow wound healing Slow wound healing 0 None Slow wound healing 1 Mild Slow wound healing 3 Moderate Slow wound healing 4 Severe Reduced muscle mass Reduced muscle mass 0 None Reduced muscle mass 1 Mild Reduced muscle mass 3 Moderate Reduced muscle mass 4 Severe Irritability Irritability 0 None Irritability 1 Mild Irritability 3 Moderate Irritability 4 Severe Nervousness/anxiety Nervousness/anxiety 0 None Nervousness/anxiety 1 Mild Nervousness/anxiety 3 Moderate Nervousness/anxiety 4 Severe Mood Swings Mood Swings 0 None Mood Swings 1 Mild Mood Swings 3 Moderate Mood Swings 4 Severe Weight Gain Weight Gain 0 None Weight Gain 1 Mild Weight Gain 3 Moderate Weight Gain 4 Severe Short term memory loss Short term memory loss 0 None Short term memory loss 1 Mild Short term memory loss 3 Moderate Short term memory loss 4 Severe Other Other 0 None Other 1 Mild Other 3 Moderate Other 4 Severe Question Title * 25. Where did you hear about us? Radio TV Channel 41 TV Channel 9 Invitation in Mail Facebook YouTube Website Other 100% of survey complete. Submit
