Men’s Health Questionnaire Men’s Health Questionnaire "*" indicates required fields Step 1 of 15 6% EmailThis field is for validation purposes and should be left unchanged.Personal InformationFull Name*Date of Birth* MM slash DD slash YYYY Email* Phone number* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Gender* Male Female Other HeightFeet*Inches*Weight* How Did you hear about us?Emergency Contact Name & Phone Name*Phone*Consent to receive automated messages/reminders: Texts Calls E-mails Marital Status* Married Single Divorced Other Other Status*Living Situation* Spouse Alone Partner Parents Children Other Other Living Situation*How would you rate your current general health?* Excellent Good Fair Poor Medical HistoryDo you have Current or past history of any of the following?(Check all that apply) High blood pressure Diabetes (Type 1 or 2) High cholesterol Heart disease Stroke Sleep apnea Depression or anxiety Thyroid disorder Hashimoto's Thyroiditis Fibromyalgia Kidney or liver disease Seizure disorder Cancer Arthritis MTHFR gene mutation Hormone Imbalance Blood clot(DVT/PE) Varicose Veins Osteoporosis Eating disorder Drug/alcohol abuse (past or current) Heart palpitations Ventricular heart problems Arrhythmia Pacemaker IBS Constipation Diarrhea GERD Heartburn Pancreatitis Diverticulitis Bowel blockage Other Other*Type of Cancer*Food/Medication Allergies?* No Yes List of Allergies* Pregnant or breastfeeding? No Yes Current medications or supplements?* No Yes Current medications or supplements List*Surgical History* No surgeries Yes Type / Date of Surgery* Family Medical History (Check applicable family members only)FatherMotherSiblings General Health InformationMeals/day?* 1 2 3 More Snacking?* Rarely Sometimes Often Exercise frequency?* Never 1–2x/week 3–5x/week Daily Sleep/night?* <5 hrs 5–6 hrs 7–8 hrs >8 hrs Alcohol use?* No Occasionally Frequently Drinks / Week*Tobacco use?* No Yes Packs/day* Recreational/illicit drug use (past or present)?* No Yes Type*Have you had your cholesterol checked?* No Yes Date* MM slash DD slash YYYY Result* Male Sexual Health Evaluation Please select the best answer for the following.Do you feel more fatigued and/or tired than usual?* None Mild Moderately Severely Have you noticed a decrease in your muscle mass?* None Mild Moderately Severely Have you experienced a loss in muscle strength?* None Mild Moderately Severely Have you noticed a decrease in your sex drive?* None Mild Moderately Severely Have you experienced a loss in height?* None Mild Moderately Severely Do you have trouble losing weight?* None Mild Moderately Severely Have you experienced difficulty in establishing and/or maintaining full erections?* None Mild Moderately Severely Do you have a decrease in spontaneous early morning erections?* None Mild Moderately Severely Do you feel a decrease in your mental sharpness?* None Mild Moderately Severely Do you experience less enjoyment in personal interest and hobbies?* None Mild Moderately Severely Consent* I confirm this information is accurate. I agree to this consent. My name represents my signature.
