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MEN'S MEDICAL HISTORY AND SYMPTOMS

TODAY'S DATE MM/DD/YYYY
FIRST NAME
MIDDLE INITIAL
LAST NAME
STREET ADDRESS 1
STREET ADDRESS 2
CITY
STATE
ZIP CODE
HOME TELEPHONE
CELL TELEPHONE
EMAIL
DATE OF BIRTH MM/DD/YYYY
AGE
HEIGHT IN
WEIGHT POUNDS
OCCUPATION
DRUG ALLERGIES
SEASONAL ALLERGIES
PET ALLERGIES
USE TOBACCO?  HOW MUCH?   PKG/DAY
USE ALCOHOL?  HOW MUCH?   /DAY/ MO
USE CAFFEINE?  HOW MUCH?   /DAY/MO
CARBONATED BEVERAGES  DIET? HOW MUCH? OZ/ DAY/WEEK/MONTH
CURRENT MEDICATIONS?
DO YOU EXERCISE?  HOW OFTEN TIMES / WEEK

MEDICAL CONDITIONS

LIST DR'S & PHONE NO'S
   
SYMPTOMS:  
DECREASE IN URINE FLOW
INCR URINARY URGE
PROSTATE PROBLEMS
DECREASED ERECTIONS
INCR FORGETFULLNESS
FOGGY THINKING
TEARFUL
DEPRESSED
MOOD SWINGS
FLUID RETENTION-BLOATING
COLD EXTREMITIES
STRESS
ANXIOUS
IRRITABLE
NERVOUS
DECR MENTAL SHARPNESS
MORNING FATIGUE
AFTERNOON FATIGUE
EVENING FATIGUE
DIFCULTY FALLING ASLEEP
DIFFICULTY SLEEPING
DECREASED STAMINA
FIBROMYALGIA
RINGING IN EARS
ALLERGIES
HEADACHES-MIGRAINES
DIZZY SPELLS
SUGAR CRAVINGS
CONSTIPATION
GOITER
COLD BODY TEMPERATURE
HOARSENESS
HAIR DRY OR BRITTLE
NAILS BREAK OR BRITTLE
SLOW PULSE RATE
RAPID HEARTBEAT
HEART PALPITATIONS
INCONTINENCE
HOT FLASHES
NIGHT SWEATS
INFERTILITY PROBLEMS
ACNE
SCALP HAIR LOSS
WEIGHT GAIN HIPS
WEIGHT GAIN WAIST
HIGH CHOLESTEROL
ELEVATED TRIGLYCERIDES
DECREASED LIBIDO
DECREASED MUSCLE MASS
DECREASED FLEXIBILITY
BURNED OUT FEELING
SORE MUSCLES
INCREASED JOINT PAIN
NECK OR BACK PAIN
BONE LOSS
THINNING SKIN
RAPID AGING
ACHES AND PAINS
IBS

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