Men’s Health Questionnaire

Email

This field is for validation purposes and should be left unchanged.

Personal Information

Full Name*

Date of Birth*

Email*

Phone number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Gender*

Male

Female

Other

Height

Feet*

Inches*

Weight*

How Did you hear about us?

Emergency Contact Name & Phone

Name*

Phone*

Consent to receive automated messages/reminders:

Texts

Calls

E-mails

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)

Father

Mother

Siblings

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*

Result*

Do you experience less enjoyment in personal interest and hobbies?*

None

Mild

Moderately

Severely

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Men’s Health Questionnaire

Personal Information

Medical History

Family Medical History (Check applicable family members only)

General Health Information

Male Sexual Health Evaluation
Please select the best answer for the following.

Men’s Health Questionnaire

Personal Information

Medical History

Family Medical History (Check applicable family members only)

General Health Information

Male Sexual Health Evaluation Please select the best answer for the following.

Male Sexual Health Evaluation
Please select the best answer for the following.