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Our Team
Dr. Alex Alonso
Samantha Fonte
Mohammed Bilal Sheikh
About
Patient Info
Contact Us
Multi Form
Home
Lifestyle Questionnaire
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9
Main Chief
Complaint
What medical concerns bring you to our office?
Lack of energy and stamina
Decreased sex drive and/or performance
Day/night physical fatigue and always tired
Loss of muscle tone and increased fat
Decrease mental alertness and mood swings
I feel good, But I can be better
Experiencing following
Symptoms
Nervousness
Anxiety
Depressed mood
Exhaustion/lacking vitality
Declining Mental / Ability / Focus/ Concentration Feeling you have passed your peak
Decreased muscle strength
Weight Gain/Belly Fat/Inability to Lose Weight
Breast Development
Feeling burned out/hit rock bottom
New Migraine Headaches
Decreased ability to perform sexually
Rapid Hair Loss
No Results from E.D. Medications
Sweats
Mood changes/Irritability
Tension
Vaginal Dryness
Dry and wrinkled skin
Swealling all over the body
Mental confusion
Bloating
Cold all the time
Hot flashes
Memory loss
Sleep problems
Joint pain
Hair is falling out
Difficult to climax sexually
Breast tenderness
Other
None of above
Sexual
Wellness
Are you sexually active?
Yes
No
Do you lack sexual drive?
Yes
No
Are you currently trying to have children?
Yes
No
Select Time
Within 1 Year
After 1 Year
No time soon
Have you developed a lack of attraction toward your partner?
Yes
No
Social
Lifestyle
Have you ever smoked?
Yes
No
How many cigarettes a day do you smoke?
Do you drink alcohol?
I don't drink
Rarely (less than 1 Wkly)
Hard liquor, 1-3 o.z. day
Hard liquor, over 3 o.z./ Day
Beer, 12 o.z./day
Beer, 2 Bot./Day
Beer, 3 bot. Or more/day
Wine, 1 Glass/day
Wine, 2 glasses/day
Wine, 3 or more glasses/day
Do you reguarly use recreational drugs?
Yes
No
Drug Name
Do you drink caffeine ?
Yes
No
How many times a day do you drink Caffeine?
Do you exercise routinely?
Yes
No
what exercise/how often?
Allergies
Medication
Allergies: Are you allergic to any drugs
Yes
No
Enter the drug name
Are you currently taking any medication
Yes
No
List medications
Medical Illnesses or
Conditions
Have you ever had or been diagnosed to have: (check all that apply)
High Blood Pressure
Blood clot and/or a pulmonary emboli
Testicular or prostate cancer
Exhaustion/lacking vitality
Rouble passing Urine or take Flomax or Avodar
Thyroid Disease
High Cholesterol
Hemochromatosis
Diabetes
Athritis
Heart Disease
Depression/ Anxiety
Elevated PSA
Chronic Liver Disease (hepatitis, fatty liver, cirrhosis)
Hemorrhoids
Stroke and/or heart attack
Psychiatric Disorder
Prostate enlargement
Cancer
Other
None
Family Medical
History
Has any blood relative ever had? ( check if Yes and indicate relationship)
Alzheimer’s
High Blood Pressure
Bleeding Disease
Depression/Suicide
Allergies
Tuberculosis
Heart Disease
Stroke
Alcoholism
Asthma
Diabetes
Heart Attack before age 55
Seizures
Mental Disorder
Cancer
Other
None
Past medical History / Medical condition
HIV
HERPES
SYPHILLIS
HEPATITIS B
HEPATISIS C
None
Autoimmune Disease
Yes
No
Name of disease
Personal
Details
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