Download Fillable Client History Form (PDF) Step 1 of 5 20% Date MM slash DD slash YYYY Name First Last Date of Birth MM slash DD slash YYYY AgeHome PhoneWork PhoneCell PhoneEmail Address SexFemaleMaleEmergency ContactPhone NumberHow did you hear about us?OccupationMarital StatusMarriedWidowedDivorced or SeparatedSingleHeightWeight Surgical HistoryList surgical procedures including plastic surgery.Other serious Illness/operationsDate of last chest x-ray MM slash DD slash YYYY Date of last EKG MM slash DD slash YYYY MedicationsNameDosageFrequency Allergies and type of reaction Medical HistoryHeart Disease Myself Family ClarificationsGall bladder disease Myself Family ClarificationsHeadaches Myself Family ClarificationsUterine Cancer Myself Family ClarificationsOsteoporosis Myself Family ClarificationsDiabetes Myself Family ClarificationsAsthma Myself Family ClarificationsLiver disease Myself Family ClarificationsOvarian Cancer Myself Family ClarificationsStroke Myself Family ClarificationsStroke Myself Family ClarificationsKidney disease Myself Family ClarificationsFibromyalgia Myself Family ClarificationsMental disorder Myself Family ClarificationsCervical cancer Myself Family ClarificationsVaricose veins Myself Family ClarificationsSeizures Myself Family ClarificationsArhtritis Myself Family ClarificationsThyroid disorder Myself Family ClarificationsHIV/Aids Myself Family ClarificationsProstate cancer Myself Family ClarificationsClotting Myself Family ClarificationsColitis Myself Family ClarificationsBreast cancer Myself Family Clarifications Nutritional SupplementsAndrostenedioneArimedexDHEAEstraceEstradiolEstriolEstroneGrowth HormoneHuman Growth HormoneMelatoninPregnenolonePremarinProgesteroneProveraTamoxifenTestosteroneThyroidVitamin AVitamin B3Vitamin B6Vitamin B12Vitamin CVitamin DVitamin EBeta CaroteneCalciumCo Q10ChromiumDigestive EnzymeFolic AcidIronMagnesiumSeleniumZincProbioticSocialAlcohol use Yes No AmountCoffee Yes No AmountSoft drink Yes No AmountTea Yes No AmountHigh sugar food Yes No AmountChewing tobacco Yes No AmountCigarettes Yes No AmountExcessive stress Yes No AmountReview of systemsCheck all that appliesHead Headaches Blurred vision Cloudy vision Hair Hair loss Dry hair Clumps of hair coming out Cardiovascular Water retention Cannot tolerate much exercise Difficult breathing Chest pain while walking Heaviness in legs Calf muscle cramp often Heart pounds easily Palpitations High blood pressure Low blood pressure Respiratory Shortness of breath Chronic lung congestion Wheezes Cough Acute congestion Gastrointestinal Constipation Diarrhea Heart burn Abdominal pain Certain foods cause ill feeling Blood in stool Epigastric pain Hernia Urinary Frequent Urination Burning with urination Incontinent issues Musculoskeletal Change in muscle mass Joint pain Limitation in motion Dermatological Dry skin Oily skin Acne Metabolic Difficulty gaining weight Difficulty losing weight Sensitivity to cold Wake up craving sweets Fatigue Feel faint Night sweats Increased thirst Craves sweets Weight loss more than 10 lbs in 6 months Weight gain more than 10 lbs in 6 months Psychological Rapid mood swings Moodiness/ change in mood Depression Lack of self-esteem Anxiety Difficulty concentrating Short attention span Forgetfulness Sleep Difficulty going to sleep Difficulty staying asleep Wake up frequently Hours of sleep per night Females OnlyFemales Only Bloating and swelling Breast tenderness Miscarriage Vaginal discharge Underactive sex drive Pelvic soreness Menstrual pain Insomnia Vaginal bumps/sores Premenstrual chest discomfort Hot flashes Night sweats Vaginal dryness Infertility Heavy menstrual bleeding Ovarian cysts Breast lump Irregular period Date of last menstrual cycle MM slash DD slash YYYY Date of last pelvic exam and pap smear MM slash DD slash YYYY ResultsDate of last Mammogram MM slash DD slash YYYY Sexually transmitted diseasesForm of birth control None IUD Diaphragm Condom Pill Sponge Foam Other Males OnlyMales Only Pain with ejaculation Difficulty maintaining erection Sexual drive underactive Premature ejaculation Pain in genital area Infertility Low sperm count Discharge from penis Rash on penis Swelling in groin Loss of urine control Frequent urination at night Date of last prostate exam MM slash DD slash YYYY ResultsLast PSA blood levelDo you use Viagra Yes No How oftenDoes it help? Yes No Maybe Do you use any other medication for sexual function? Yes No Please listNameThis field is for validation purposes and should be left unchanged. Δ
