Pre Consultation Form General How did you hear about our clinic? Last Name First & Middle Names Address City/Province/Zip/Post Code Date of Birth Email Address Home Phone Mobile Phone Your Profession & Nationality Please Note: Not all questions in this questionnaire are compulsory to answer, if there is a compulsory question that you did not answer, when you try to Submit the questionnaire you will see this warning message, **Please complete all required fields!** Scroll back up the page and look for the question highlighted in red. (Please assign a numerical value from 1-7 to each goal in order of importance, with “1” being MOST important and “7” being LEAST important.)Improved Energy 1 2 3 4 5 6 7 Improved Well Being 1 2 3 4 5 6 7 Weight Loss 1 2 3 4 5 6 7 Improved Sexual Function/Sex Drive 1 2 3 4 5 6 7 Improved Physical Stamina/Endurance/Strength 1 2 3 4 5 6 7 Management of Chronic Illness (Heart Disease, Type II Diabetes, Other) Heart Disease Type II Diabetes Other <h3.How would you describe your general health? Excellent Good Fair Poor Please indicate any serious conditions, illnesses or injuries, and any surgeries (including cosmetic), or hospitalizations; along with approximate dates: Which medications, either by doctor’s orders or over the counter, are you taking, or have you taken in the past 6 months? Antacids Antibiotics Anticonvulsants Antidepressants Appetite Suppressants Birth control pills Blood pressure meds Chemotherapy Cholesterol-lowering medication Cortisone/Prednisone Diuretics H2 Blockers/Ulcer medication Hormone replacement Laxatives Pain Relievers Sedatives Sleeping medications Thyroid medication Please list, by name, any prescription medications, over-the-counter medications, and all vitamins/supplements/herbs you take regularly at this time. Include dosage if known. NOTE: PLEASE BRING EACH OF THESE WITH YOU TO YOUR FIRST OFFICE VISIT. Family HistoryDo you have a family history of any of the following diseases or conditions? When answering, include your parents, brother/sisters, and grandparents, if known.Disease/ConditionAlzheimer’s Yes No Anemia Yes No Arthritis Yes No Asthma Yes No Cancer Yes No Diabetes Yes No Epilepsy Yes No Heart Disease Yes No Hypertension Yes No Kidney Disease Yes No Mental Illness Yes No Multiple Sclerosis Yes No Parkinson’s Yes No Stroke Yes No Review Of Systems:Please Check any that applyEars, Nose, and Throat Hearing Loss Ringing in Ears Altered Sense of Smell Trouble Swallowing Neck Pain/Stiffness Lungs Nonproductive Cough Pain with Breathing at Rest Pain with Breathing with Exertion Pain with Inspiration Wheezing Coughing up Blood Short of Breath with Exertion Cardiovascular System Chest Pain/Pressure at Rest Chest Pain/Pressure with Exertion Heart Palpitations Normal Tolerance to Exercise Pain in Legs with Walking Cold Hands/Feet Fainting Lightheadedness Hematology (Blood) Anemia Allergic Hives Gastrointestinal System Pain with Swallowing Abdominal Pain Nausea Vomiting Neurological System Headache Loss of Sensation in any part of the body Weakness of any Extremity Uncontrolled Muscle Movements Dizziness Problems with Walking Speech Disturbance Genitourinary System Pain with Urination Urinary Frequency Urinary Urgency Blood in Urine Trouble Starting Stream Difficulty Stopping Stream (Men) Erectile Dysfunction Musculoskeletal System Joint Pain (any Joint) Pain in any Muscles Muscle Weakness General Constitution Fatigue Night Sweats Weight Loss Weight Gain Integumentary (Skin) System Rashes Psychiatric Depressed Anxious/Nervous Endocrine Goiter (Lump in Neck) Appetite Change Heat or Cold Intolerance Eyes Headache Blurry Vision Double Vision Visual Changes General:1. Have you ever had an abnormal PSA test or prostate exam? Yes No If yes, please provide details if known (e.g. age, treatment, follow-up) 2. Do you have a family history of Prostate Cancer? Yes No If yes, please provide details if known (e.g. relation, age of diagnosis, treatment) 3. Have you ever had any of the following? (Check all that apply and provide details) Kidney Stones Blood in the urine Bladder/Kidney infection Surgery on the urinary tract Vasectomy Please provide details if known 4. Do you have or have you ever had Venereal Disease or any other STD? International Index of Erectile Function (IIEF-5/SHIM)Instructions: These questions ask about the effects your erection problems have had on your sex life. Please answer the following questions as honestly and clearly as possible. We understand the sensitive nature of these questions; therefore, all information is strictly confidential.1. Over the past 6 months, how do you rate your confidence that you could keep an erection? Very Low Low Moderate High Very high 2. Over the past 6 months, when you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)? Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always 3. Over the past 6 months, during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always 4. Over the past 6 months, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always 5. Over the past 6 months, when you attempted sexual intercourse how often was it satisfactory for you? Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always International Prostate Symptom Score (IPSS)Instructions: These questions ask about your urinary symptoms, OVER THE PAST 4 WEEKS Incomplete Emptying:Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Frequency:Over the past month, how often have you had to urinate again less than two hours after you finished urinating? Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Intermittency:Over the past month, how often have you found you stopped and started again several times when you urinated? Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Urgency:Over the last month, how difficult have you found it to postpone urination? Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Weak stream:Over the past month, how often have you had a weak urinary stream? Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Straining:Over the past month, how often have you had to push or strain to begin urination? Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Nocturia:Over the past month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning? None 1 time 2 times 3 times 4 times 5 times or more Quality of life due to urinary symptoms:If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? Delighted Pleased Mostly Satisfied Mixed - Equally Satisfied/Dissatisfied Mostly Dissatisfied Unhappy Terrible Prior Anabolic/Androgenic Steroid Use**(Skip section if not applicable) **1. Have you ever used anabolic steroids including Testosterone (either prescribed or not prescribed) anytime during your life? Yes No 4. Did you use Post Cycle Therapy (PCT) to restore your own testosterone production? Yes No Male Reproductive:Have you had any of the following symptoms?Discharge or Sores? Yes No Sometimes In the past Testicular masses? Yes No Sometimes In the past Testicular pain? Yes No Sometimes In the past Self-Testicular Exams? Yes No Sometimes In the past Premature Ejaculation? Yes No Sometimes In the past Male Patient History Questionnaire (check Yes or No)Have you had any muscle weakness, fatigue or loss of muscle mass? Yes No Has your interest in sex (libido) declined? Yes No Do you have spontaneous erections (without medication or other aid)? Yes No Have you experienced a decline in your energy levels or stamina? Yes No Have you lost self-confidence, motivation or initiative? Yes No Have you experienced a decline in memory or concentration ability? Yes No Have you had any sleep disturbance or problems breathing while asleep? Yes No Do you have mood swings or depression? Yes No Have you noticed any increase in aggressiveness? Yes No Do you have any breast tenderness or enlargement? Yes No Has your need to shave decreased? Yes No Have you noticed any significant change in the size of your testicles? Yes No Do you have periodic hot flashes or sweats? Yes No Have you ever had fertility problems (inability to have children)? Yes No Are you considering having any (or more) children? Yes No Social History (check Yes or No)Do you use tobacco? Yes No Did you use tobacco in the past? Yes No Do you drink alcoholic beverages? Yes No Coagulation Questionnaire 1.Do you have a FAMILY history of clotting (Deep Vein Thromhosis/DVT)/Pulmonary Embolism(PE): Stroke(CVA); Trans-Ischemic Attack(TIA); thrombosis in the artery? No (Please Proceed to the next question) Yes Family history of venous thrombosis: 2.Have you had any previous episodes of clotting (Deep Vein Thrombosis/DVT)/Pulmonary Embolism(PE); Stroke(CVA); Trans-Ischemic Attack(TIA); thrombosis in the artery? No (Please Proceed to the next question) Yes Personal History of venous thrombosis; 3.Are YOU a first-degree relative of someone with a PROVEN inherited clotting disorder? No Yes Appointment Reminder Text/EmailMay we send you a text message or email reminder the day before your appointment? (We will not send you any other text messages or emails without prior approval.) Yes Please No Thanks Sorry about this one, please prove you are not a Robot by adding the 5 characters above, exactly as they are shown, ie: UPPER or lower case. Be sure to click Submit Questionnaire to send your results! We will review your responses with you at your consultation, thank you for taking the time to complete this form. Time's up
