Intake Form Medical Evaluation Form An in-depth intake form for maximum assessment Step 1 of 8 12% Goal Importance Through our desire to provide you with the most focused and personalized healthcare experience, we would like to understand the primary reason that has brought you to the clinic today. Please take a moment to identify which of the following you are hoping to achieve through your care at Maximum Performance Wellness Center.Improved Energy1 = Very Important2 = Important3 = Somewhat Important4 = Indifferent5 = Somewhat unimportant6 = Unimportant7 = Very unimportantImproved Well-Being1 = Very Important2 = Important3 = Somewhat Important4 = Indifferent5 = Somewhat unimportant6 = Unimportant7 = Very unimportantWeight Loss1 = Very Important2 = Important3 = Somewhat Important4 = Indifferent5 = Somewhat unimportant6 = Unimportant7 = Very unimportantImproved Sexual Function/Sex Drive1 = Very Important2 = Important3 = Somewhat Important4 = Indifferent5 = Somewhat unimportant6 = Unimportant7 = Very unimportantImproved Physical Stamina/Endurance/Strength1 = Very Important2 = Important3 = Somewhat Important4 = Indifferent5 = Somewhat unimportant6 = Unimportant7 = Very unimportantManagement of a Chronic IllnessHeart Disease, Type II Diabetes, other…1 = Very Important2 = Important3 = Somewhat Important4 = Indifferent5 = Somewhat unimportant6 = Unimportant7 = Very unimportantOther GoalNoYesWhat is your other goal?Level of importance?1 = Very Important2 = Important3 = Somewhat Important4 = Indifferent5 = Somewhat unimportant6 = Unimportant7 = Very unimportant Patient InformationHow did you hear about our clinic?*Name* First Last Preferred NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Home PhoneMobile PhonePreferred method of contact*EmailHome PhoneMobile PhoneProfessionNationalityMay 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.YesNoEmergency ContactName First Last Home PhoneMobile PhoneRelation to Patient Health QuestionnaireHow would you describe your general health?ExcellentGoodFairPoorMedical HistoryHeightMaximum WeightCurrent WeightDate of Last Physical ExamDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of Last Prostate ExamDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Allergies/HypersensitivitiesDrugs*Please indicate any serious conditions, illnesses or injuries, and any surgeries (including cosmetic), or hospitalisations; 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.Column 1Column 2 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. Alzheimer’s Anemia Arthritis Asthma Cancer Diabetes Epilepsy Heart Disease Hypertension Kidney Disease Mental Illness Multiple Sclerosis Parkinson’s Stroke More InformationReview of Systems Please check ANY that apply.Ears, 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 GeneralDo you sleep well?YesNoSometimesPastAverage 6-8 hours?YesNoSometimesPastHave a supportive relationship?YesNoSometimesPastHave a history of abuse?YesNoSometimesPastDrug/alcohol dependence?YesNoSometimesPastSpend time outside?YesNoSometimesPastExercise daily?YesNoSometimesPastMen’s Health Inventory1. Have you ever had an abnormal PSA test or prostate exam?*YesNoMore InformationPlease provide details if known (e.g. age, treatment, follow-up)2. Do you have a family history of Prostate Cancer?*YesNoMore InformationIf 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. Kidney stones Blood in the urine Bladder/Kidney infection Surgery on the urinary tract Vasectomy More InformationIf yes, please provide details.4. Do you have or have you ever had Venereal Disease or any other STD?YesNoMore InformationIf yes, please provide details. International Index of Erectile Function (IIEF-5/SHIM) 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 confidential1. Over the past 6 months, how do you rate your confidence that you could keep an erection?*Very LowLowModerateHighVery high2. 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 neverA few times (much less than half the time)Sometimes (about half the time)Most times (much more than half the time)Almost always or always3. 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 neverA few times (much less than half the time)Sometimes (about half the time)Most times (much more than half the time)Almost always or always4. Over the past 6 months, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?*Extremely difficultVery difficultDifficultSlightly difficultNot difficult5. Over the past 6 months, when you attempted sexual intercourse how often was it satisfactory for you?*Almost never or neverA few times (much less than half the time)Sometimes (about half the time)Most times (much more than half the time)Almost always or alwaysInternational 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?0 = Not at all1 = Less than 1 time in 52 = Less than half the time3 = About half the time4 = More than half the time5 = Almost alwaysFrequency*Over the past month, how often have you had to urinate again less than two hours after you finished urinating?0 = Not at all1 = Less than 1 time in 52 = Less than half the time3 = About half the time4 = More than half the time5 = Almost alwaysIntermittency*Over the past month, how often have you found you stopped and started again several times when you urinated?0 = Not at all1 = Less than 1 time in 52 = Less than half the time3 = About half the time4 = More than half the time5 = Almost alwaysUrgency*Over the last month, how difficult have you found it to postpone urination?0 = Not at all1 = Less than 1 time in 52 = Less than half the time3 = About half the time4 = More than half the time5 = Almost alwaysWeak stream*Over the past month, how often have you had a weak urinary stream?0 = Not at all1 = Less than 1 time in 52 = Less than half the time3 = About half the time4 = More than half the time5 = Almost alwaysStraining*Over the past month, how often have you had to push or strain to begin urination?0 = Not at all1 = Less than 1 time in 52 = Less than half the time3 = About half the time4 = More than half the time5 = Almost alwaysNocturia*Over the past month, 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?0 = None1 = 1 time2 = 2 times3 = 3 times4 = 4 times5 = 5 times or moreQuality 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?0 = Delighted1 = Pleased2 = Mostly satisfied3 = Mixed – about equally satisfied and dissatisfied4 = Mostly dissatisfied5 = Unhappy6 = Terrible Coagulation Questionnaire1. Do you have a FAMILY history of clotting?* (Deep Vein Thrombosis/DVT)/Pulmonary Embolism (PE); Stroke (CVA); Trans-Ischemic Attack (TIA); thrombosis in the arteryNoYesMore InformationFamily 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 arteryNoYesMore InformationPersonal history of venous thrombosis:3. Are YOU a first-degree relative of someone with a PROVEN inherited clotting disorder?*NoYesRelationship to you:Prior Anabolic/Androgenic Steroid Use Skip section if not applicable1. Have you ever used anabolic steroids including Testosterone (either prescribed or not prescribed) anytime during your life?*YesNo2. Which steroids did you use? What were the doses? How long did you use each?3. When was your last cycle and how long did it last?4. Did you use Post Cycle Therapy (PCT) to restore your own testosterone production?YesNoMale ReproductiveDischarge or sores?YesNoSometimesPastTesticular masses?YesNoSometimesPastTesticular pain?YesNoSometimesPastSelf-testicular exams?YesNoSometimesPastPremature ejaculation?YesNoSometimesPast Male Patient History QuestionnaireHave you had any muscle weakness, fatigue or loss of muscle mass?*YesNoHas your interest in sex (libido) declined?*YesNoDo you have spontaneous erections (without medication or other aid)?*YesNoDo you experience erections during the night, or in the morning upon waking?*YesNoHave you experienced a decline in your energy levels or stamina?*YesNoHave you lost self-confidence, motivation or initiative?*YesNoHave you experienced a decline in memory or concentration ability?*YesNoHave you had any sleep disturbance or problems breathing while asleep?*YesNoDo you have mood swings or depression?*YesNoHave you noticed any increase in aggressiveness?*YesNoDo you have any breast tenderness or enlargement?*YesNoHas your need to shave decreased?*YesNoHave you noticed any significant change in the size of your testicles?*YesNoDo you have periodic hot flashes or sweats?*YesNoHave you ever had fertility problems (inability to have children)?*YesNoAre you considering having any (or more) children?*YesNoSocial HistoryDo you use tobacco?*YesNoIf yes, how much?Did you use tobacco in the past?*YesNoHow Long? When did you stop?Do you drink alcoholic beverages?*YesNoIf yes, how much?Please specify which clinic you wish to visit.* Pattaya Bangkok Captcha Δ