Medical History
Hormone Optimization Consultation -MALE
NAME:_____________________________________________
DATE:______________________________________________
CELL PHONE:______________________________HOME PHONE:_______________________
ADDRESS:________________________________CITY_________________STATE__________
ZIP_____________________
D.O.B.:________________________________
SOCIAL SECURITY #:____________________________
EMAIL ADDRESS:______________________________ CAN WE SEND EMAILS: YES NO
Physician______________________________________________________________
PLEASE LIST THE FOLLOWING:
ALLERGIES:____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
CURRENT MEDICATIONS- PRESCRIPTION & NONPRESCRIPTION( name/dose/ reason for
taking):_______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
CURRENT SUPPLEMENTS (name & dose):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
HOSPITAL ADMISSIONS/SURGERIES (not including pregnancies):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Medical History
Enter “X” & indicate age & dates for all questions which have ever applied to you. Enter “C”
for current ongoing problems, details & dates.
Ringing in ear
Dizzy Spells
Abdominal Pain- Chronic
Have bowel movement every___day(s)
Fainting Spells
Failing Vision
Eye Pain
Hoarseness- prolonged
Hay Fever/Allergies
Frequent: [ ] Constipation
[ ] Diarrhea
Urination- Overactive Bladder
Overnight less than twice
More than 8 times/24 hrs
Urgency to urinate
Shortness of Breath:
On exertion
Laying flat
Chest Pain
High Blood Pressure
Heart Murmur
Decrease in urinary force/flow
Painful urination
Stress incontinence-urine leakage
Recent weight- [ ] Gain [ ] Loss: ________lbs
Anemia
Bruise Easily
Swollen Ankles
Irregular Pulse
Palpitations
Leg Pain- when walking
Varicose Veins/Phlebitis
Chronic Fatigue
Diabetes
Thyroid Disease
Numbness/tingling sensations
Headaches- frequent
Cold Numb Feet
Loss Appetite- Recent
Difficulty Swallowing
Heartburn
Bone Fracture/Joint Injury
Arthritis: type/location
------Social History----[ ] Coffee_________ [ ] Tea________cups/day
Alcohol # of drinks a day_____
A week_______
Fractures after 50? [ ]Yes [
]No
Joint Pain
Location:
Rashes
Hives
Smoking:_________cigarettes/day?__________#years
Recreational drugs:
Psoriasis
Eczema
Males (complete the following two sections)
Symptoms at this time
None
Mild
Moderate
Severe
Extreme
More
than Half
of the
time
Almost
at always
Decline in your feeling of general well
being
Joint pain & muscular ache
Excessive sweating
Sleep problems
Increased need for sleep, often tired
Irritability
Nervousness
Anxiety
Physical exhausting/lack of vitality
Decrease in muscular strength
Depressive Mood
Feeling that you have passed your peak
Feeling burnt out, having hit rock bottom
Decrease in beard growth
Decrease in ability/frequency to perform
sexually
Decrease in sexual desire/libido
Males:
Over the past month
How often have you:
Had sensation of not emptying bladder
completely after urinating?
Had to urinate again less than 2 hrs.
after urinating?
Stopped and started several times
when you urinated?
Found it difficult to postpone
urination?
Had to push or strain to begin
urinating?
Not
At
All
Less
than 1
time in
5
Less than
Half the
time
Half the
time
Typically get up to urinate from
bedtime to getting up?
SCREENING TESTS
SCREEN
DATE
ABNORMAL?
Cholesterol/Lipids
SCREEN
DATE
ABNORMAL?
Dental Exam
Eye Exam
Skin Exam
Rectal/Colonoscopy
PSA (prostate test)
Prostate Exam
Blood Sugar
Pap Smear
Mammogram
Bone Density
Vascular
UItrasound
IF A BLOOD RELATIVE HAS SUFFERED ANY OF THE FOLLOWING-PLEASE CIRCLE THE NUMBER
AND INDICATE WHICH RELATIVE(S). PROVIDE ADDITIONAL DETAILS
1. ANEMIA
6. ALCOHOLISM
2. ASTHMA
3. EPILEPSY
4. HEPATITIS
7. BLEEDS EASILY
8. GLAUCOMA
9. HYPERTENSION
5. OSTEOPOROSIS
10. STROKE
11. ALZHEIMER’S
DX
12. CANCER (TYPE)
13. HAY FEVER
14. LIPID DISORDER
15. THYROID
DISEASE
16. ARTHRITIS
17. DIABETES
18. HEART DISEASE
19. MENTAL
ILLNESS
20. HIP FRACTURE
AFTER AGE 50
DETAILS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Exercises
Current Sources of Stress
My Primary Health Concerns
List any diets you have been on during the past 12 months, along with the reason(s) for
following it, the benefits or problems you experienced with it, and the reason(s) for stopping
any diet.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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CONSENT TO FILE INSURANCE/FINANCIAL RESPONSIBILITY
Your medical health coverage is a contract between you and your insurance company. ReGeneration,
P.C. will file in Network medical insurance claims. In network insurance company co-payments and
deductibles are due at time of service. Our facility insurance claims are serviced by Medical Billing
Associates.
Patients with out of Network insurance are responsible for payment in full at time of service.
A Billing statement will be prepared for you to file with your insurance company.
By my signature below, I give my consent to ReGeneration, P.C. to file a medical claim to my carrier. I
understand that all unpaid charges are my responsibility. If you have any questions please feel free to
ask.
Printed Name_________________________________________________________
Signature of patient or legal guardian_______________________________________________
Date:___________________________________
A 24 hour notice of cancellation is required. If your cancellation is less than 24 hours or you do not show for your appointment a
rescheduling fee will apply before for your next appointment. This is for the consideration of our patients that are waiting for an
earlier appointment and allows us the necessary time to contact them with appointment availability. We thank you for understanding
regarding this policy that has proven to be very successful in meeting our patents needs.
Patient Signature_________________________________________
Date________________