andropause health history questionnaire - Sugar Land Medical ...

ANDROPAUSE HEALTH HISTORY QUESTIONNAIREDate: __________________Name: _________________________________ DOB:_________________ Age:______Address: ________________________________________________________________City_________________________________ State: _______________ Zip:___________Phone: ______________ Cell: __________________ Email: ______________________Gender: Male Female Height: ____________ Weight: ________________Blood Pressure:_____ Temp:_____ Pulse:______ Resp:_______Primary MD_____________________________________________________________Andropause Symptoms and Related Conditions – Please check the symptoms that most accurately describe how youare feelingNO ISSUE MILD MODERATE SEVERELOWTESTOSTERONEDEPRESSIONFATIGUEIRRITABLITYJOINT ACHINESSLOW SENSE OFWELL BEINGMUSCLE LOSSFAT GAINPROTUBERATEABDOMENLOW LIBIDODECREASEDMORNINGERRECTIONSERECTIONS NOTAS HARDDIFFICULTYHAVING ORGASMWhen did your health concerns begin?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Past Medical HistoryBlood Clots Heart Attack OsteoporosisCancer Hypertension ProstateProblemsDiabetes Hypothyroid StrokeElevatedCholesterolLung diseaseOtherPast SurgeriesProstatesurgeryDate TURP Prostate forCancerOther Surgeries:__________________________________________________________Andropause LabsPreviousTestosterone lab testDate Last PSA DatePrior Hormone TherapyExplainPatient History & PhysicalGeneral Fatigue Insomnia SleepinessSkin Sweating Rash Acne JaundiceNeuro/Psychiatric Depression Anxiety Seizures DizzinessEENT Allergies SinusInfectionsSnoring VisionChangesEndocrine ThyroidProblemsChanges inlibidoPulmonary Cough Wheezing Hemoptysis DOECardiac Chest pain Chest painw/exertionNocDyspneaEdemaGI Adb Pain Constipation Diarrhea Blood inStoolUrinary Freq Uti’s Frequency Urgency NocturiaMusculoskeletalWeakStreamJointachinessCan’t emptybladderSwellingRednessPatient Name:____________________________________________________________

Objective (Check mean normal findings)Additional Notes:General x ______________________________________________________Psych x ______________________________________________________Thyroid x ______________________________________________________Neck x ______________________________________________________COR x ______________________________________________________Lungs x ______________________________________________________Breast x ______________________________________________________Abdomen x ______________________________________________________Skin x ______________________________________________________Prostate Normal Mod. Enlarged Enlarged Boggy Suspicious AreaLAB:H and HPSAFree PSATestosterone TotalTestosterone FreeAlbuminCalculated Bio-Available T.Assessment Plan:Hypogonadism:___________________________________________________________Plan Notes:______________________________________________________________________________________________________________________________________Follow UpRepeat PSA, H and H Test_________________________ In 6 Months: _____________Repeat DRE ____________________________________ In 6 Months: _____________With Primary: ____________________________________________________________Bio-Identical Testosterone Replacement Compounded Prescription OrderDaily: Use all crèmes prescribed dailyNote: 1ml = 1gm or 1/2ml = 1/2gm of Transdermal GelTestosteroneTransdermalGel(100gm/gm)10%Sig: ½ ml daily#45gmSig: 1ml q AM,1/2ml q PM#135gmSig: 1ml daily#90gmSig: 1ml q AM,1ml q PM #180Refills: __________________________ MD/NP/PA Signature:____________________

Family History (Please write which family member next to disease)Breast Cancer Heart Disease Diabetes OsteoporosisOvarian/UterineCancerHypertensionThyroidProblemsProstate Cancer Hyperlipidemia RheumatoidArthritisColon Cancer Stroke OsteoarthritisSocial History/HabitsOccupation:______________________________________________________________Tobacco: ___________________ Packs a day?______________ Year quit?___________Caffeine Intake/day?_______________ Alcohol intake per week?___________________Diet________________________ Zone:____________ Atkins_________ Low Carb____Number of meals per day? 1 2 3 4 or moreExericse days/week?_______________________________________________________Aerobic/Weights/Stretch____________________________________________________Drugs (please describe how long, how often)_____________________________________________________________________AllergiesMedication Allergies (please describe symptoms)___________________________________________________________Other Allergies (Molds,Chemicals, etc..) ____________________________________________________________________MedicationsMedicationsVitamins/OTCPreventive MedicineDate of last rectalexamDate of last bonedensityDate of lastcolonoscopyDate of last cardiacstress testOsteopeniaOsteoporosisNormalNormalNormalNormalNot NormalNot NormalNot NormalNot NormalPatient Signature:____________________________________ Date:________________