Medical History Questionnaire

This questionnaire is for confidential medical evaluation only. Your true and accurate medical history is required for the Doctor to issue you prescriptions. A copy of your drivers license is also required

Your name*

Please select your counselor's name or choose "New Patient."

Address

Street Address

Street Address Line 2

City

State

Postal/Zip Code

Country

Phone*

Email*

Birth Date:*

Driver's License Number:*

Marital Status:

Height:

Weight:

Occupation:

If 'other' please let us know which one.

If any answers above are checked “Yes”, please explain.

Do you drink?

Yes

No

If “yes”, how many drinks per day and/or week?

Do you exercise?

Yes

No

If “yes”, how often?

How many hours of sleep do you get per night?

How would you rate your libido?

Great

Sometimes good sometimes no libido

No libido

Please list ALL medications by name and dosage (including supplements) that you take on a daily basis:

Are you currently on Hormone Replacement Therapy

Yes

No

If male, would you like improvement of erection?

Yes

No

If female, would you like improvement of lubrication?

Yes

No

Do you feel good about your body image and weight?

Yes

No

Please Explain:

Please list any drug allergies:

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