Male New Patient Intake
Please complete the following form in its entirety:
Full Name
Date
Preferred Clinic location
Bozeman
Billings
Helena
Missoula
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Date of Birth
Age
Weight
Goal Weight
Home Address
City
State
ZIP
Occupation
Cell Phone Number
May we send messages via text regarding appts to your cell?
Yes
No
Other Phone
Email
Marital Status (check one)
Married
Divorced
Widow
Living with Partner
Single
Social:
I am sexually active
I have completed my family
My sex life has suffered
I want to be sexually active
I have NOT completed my family
I have not been able to have an orgasm or it is very difficult
I do not want to be sexually active
Activity Level
Low – sedentary
Moderate – walk/jog/workout infrequently
Average – walk/jog/workout 1 to 3 times per week
High – walk/jog/workout regularly 4+ times per week
Habits:
I smoke cigarettes or cigars
I drink alcoholic beverages
I use e-cigarettes
I drink more than 10 alcoholic beverages a week
I use caffeine
Medical history
High blood pressure or hypertension
Heart disease
Atrial fibrillation or other arrhythmia
Blood clot and/or a pulmonary embolism
Depression/anxiety
Chronic liver disease (hepatitis, fatty liver, cirrhosis)
Arthritis
Hair thinning
Sleep apnea
High cholesterol
Stroke and/or heart attack
HIV or any type of hepatitis
Hemochromatosis
Psychiatric disorder
Thyroid disease
Diabetes
Lupus or other autoimmune disease
Hoshimoto’s Disease
Medications currently taking (list all w special attention to statins, thyroid or reductase Rx)
Are you currently doing Hormone Replacement Therapy?
Yes
No
If yes, what hormone therapy are you receiving?
Past Hormone Replacement Therapy now discontinued
Have you ever had any issues with local anesthesia?
Yes
No
Do you have a latex allergy?
Yes
No
List all Drug Allergies
Family History
Heart disease
Diabetes
Osteoporosis
Alzheimer’s/dementia
Breast cancer
Other
List any Cancer diagnosis
Health Issues *
Thyroid Tumors
Acute Pancreatitis
Acute Gallbladder
Hypoglycemia
Type 1 Diabetes
Kidney Injuries
Hypersensitivity
Diabetic Retinopathy
I am currently taking Insulin
Increase in Heart Rate
Suicidal Behavior
Pertinent medical/surgical history:
Elevated PSA
Trouble passing urine
Taking medicine for prostate or male-pattern balding
History of anemia
Vasectomy
Erectile dysfunction
Recent Urology Consultation
Testicular or prostate cancer
Prostate enlargement or BPH
Kidney disease or decreased kidney function
Frequent blood donations
Non-cancerous testicular or prostate surgery
Severe snoring
Taking medicine for high cholesterol
Birth Control Method
Not applicable
None - planning pregnancy in the next year
Depend on partner’s contraception.
Vasectomy
Condoms
Joint Issues
Spine
Neck
Shoulders
Knees
Hips/pelvis
Hands/wrist
Ankle/feet
Please list any other information you feel would be helpful for the medical staff,
Primary Care Physician (PCP)
Primary Care Physician Phone
In case of emergency, who should we contact:
Emergency Contact Phone
Relationship to Emergency Contact
Signature
Clear
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