Male Consultation Form

Date Date / MM / DD YYYY
Personal Information
Name Name First Last
Street Address
State
City
Zip Code
Phone
Work Phone
Fax
Email
Height
Weight
BMI (Pharmacist will calculate - BMI = Weight in kg/Height in meters²)
BMI Results for Adults Over 35:

19-26.9 Recommended
27-29.9 Overweight
30-39.9 Obese
40 (+) Morbidly Obese
Date of Birth Date of Birth / MM / DD YYYY
Waist Circumference
Waist: Hip Ratio (waist/hip)
Medical Status:
Primary Health Care Practitioner/Physician
Phone
Fax
Primary Health Care Practitioner/Physician Address Primary Health Care Practitioner/Physician Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Other Physicians Currently Seeing:
General Health

General Health Excellent Good Fair Poor
Medical & Social History: Please check the following that apply to you.

Medical & Social History: Please check the following that apply to you. High Blood Pressure High Cholesterol Cardiovascular Disease Diabetes Mellitus Osteoporosis Benign Prostatic Hyperplasia Tobacco Use Asthma/COPD Alcohol Use Erectile Dysfunction Insomnia Malnutrition Depression Cancer Other
If you checked Cancer, please explain.
If you checked Other, please explain.
Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them:
Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc): Other:
Names of ALL Vitamins, Supplements, Non-prescription medicines, or other OTC products that you are currently using:
Drug Allergies
Family History: List Important Diseases
Mother
Living Deceased
Father
Living Deceased
Brothers
Living Deceased
Sisters
Living Deceased
Aunts
Living Deceased
Uncles
Living Deceased
Paternal Grandma
Living Deceased
Paternal Grandpa
Living Deceased
Maternal Grandma
Living Deceased
Maternal Grandpa
Living Deceased
Do you feel more fatigued and/or tired than usual?

Do you feel more fatigued and/or tired than usual? Not Applicable Mild Moderate Severe
Have you noticed a decrease in your muscle mass?

Have you noticed a decrease in your muscle mass? Not Applicable Mild Moderate Severe
Have you experienced a loss in muscle strength?

Have you experienced a loss in muscle strength? Not Applicable Mild Moderate Severe
Have you experienced an increase in joint and/or muscle pains?

Have you experienced an increase in joint and/or muscle pains? Not Applicable Mild Moderate Severe
Have you noticed an increase in your waist size?

Have you noticed an increase in your waist size? Not Applicable Mild Moderate Severe
Do you have trouble losing weight?

Do you have trouble losing weight? Not Applicable Mild Moderate Severe
Have you experienced a loss in height?

Have you experienced a loss in height? Not Applicable Mild Moderate Severe
Do you have a decrease in your sex drive?

Do you have a decrease in your sex drive? Not Applicable Mild Moderate Severe
Have you experienced difficulty in establishing and/or maintaining
full erections?

Have you experienced difficulty in establishing and/or maintaining
full erections? Not Applicable Mild Moderate Severe
Have you experienced changes in your usual sleep pattern?

Have you experienced changes in your usual sleep pattern? Not Applicable Mild Moderate Severe
Do you feel a decrease in your mental sharpness?

Do you feel a decrease in your mental sharpness? Not Applicable Mild Moderate Severe
Have you had trouble concentrating?

Have you had trouble concentrating? Not Applicable Mild Moderate Severe
Do you experience less enjoyment in personal interests and hobbies?

Do you experience less enjoyment in personal interests and hobbies? Not Applicable Mild Moderate Severe
I am ________ years old
I Feel ________ years old

Male Consultation Form

Male Consultation Form

Personal Information

BMI Results for Adults Over 35:

Medical Status:

Family History: List Important Diseases