10887 N. Military Trail Suite 7 Palm Beach Gardens, Fl 33410 Ph: 561-537-0537 Fax: 561-370-6843 www.youthfulbalance.net Patient Medical History Form Name: Mailing Address: Billing Address: Date of Birth: Phone: SSN Number: Email: Primary Care Provider and Phone Number: List prescription medications, including vitamins and supplements that you are taking: Drug sensitivities and/or drug allergies: Height Please check yes or no for each: Heart Failure/Heart Attack Atrial Fibrillation (arrhythmia) Heart valve disorders Stent Hypertension Clotting Disorders Stroke Anemia Thyroid Disease Diabetes Cholesterol Problems Breast Cancer Ovarian Cancer Weight Personal History: Yes No Family History: Yes No 10887 N. Military Trail Suite 7 Palm Beach Gardens, Fl 33410 Ph: 561-537-0537 Fax: 561-370-6843 www.youthfulbalance.net Please check yes or no for each: Uterine Cancer Skin Cancer Prostate Cancer Prostate Problems Erectile Dysfunction Liver Disease Kidney Disease Asthma/COPD Anxiety Depression Orthopedic or muscle disorders Fibromyalgia Back problems Gastrointestinal ulcers Arthritis Personal History: Yes No Family History: Yes Please list any hospitalizations and/or surgeries or any additional information regarding your health: LIFESTYLE INFORMATION Do you smoke? If so, how much? Do you drink alcohol? If so, how much? Do you exercise regularly? If so, how much? Yes No No 10887 N. Military Trail Suite 7 Palm Beach Gardens, Fl 33410 Ph: 561-537-0537 Fax: 561-370-6843 www.youthfulbalance.net MALE PATIENTS ONLY-PLEASE ANSWER ALL OF THE QUESTIONS BELOW: Choose yes or no for each: Yes History of Hormone replacement therapy (HRT)? No Adverse/unwanted side effects from HRT? Are you currently on Testosterone? If yes, in what form? What is the dosage and frequency of the above mentioned medications? Please rate on a scale of 0-10 (0 being the worst and 10 being the best) Mood Energy Libido FEMALE PATIENTS ONLY-PLEASE ANSWER ALL OF THE QUESTIONS BELOW: Choose yes or no for each: Yes Currently pregnant? History of hormone replacement therapy (HRT)? No Adverse/unwanted side effects of HRT? Are you currently on HRT now? If yes, in what form? What is the dosage and frequency of the above mentioned medications? When is the last time you took those medications? Have you ever had a hysterectomy? If so, total or partial? When? Form of contraception, if any? Date of last period? Normal? Last mammogram?Normal? Last pap smear? Normal? Please select yes or no if you are experiencing any of the following symptoms, regardless if you are on hormone replacement therapy or not. Choose yes or no for each: Yes No Hot flashes Night sweats Vaginal dryness Mood swings Breast tenderness Sleep disturbances Water retention Dry skin/Dry hair 10887 N. Military Trail Suite 7 Palm Beach Gardens, Fl 33410 Ph: 561-537-0537 Fax: 561-370-6843 www.youthfulbalance.net Please rate on a scale of 0-10 (0 being the worst and 10 being the best) Mood Energy Libido MEN AND WOMEN, PLEASE ANSWER THE QUESTIONS BELOW: Please select yes or no if you are experiencing any of the following symptoms, regardless if you are on hormone replacement therapy or not. Yes No Choose yes or no for each: Decreased desire and ability to exercise Fatigue Decreased sense of well being Increasingly stressed Decreasing memory or ability to focus Decreasing loss of lean muscle mass Increased fat deposits Loss of concentration Difficulty sleeping Thinning or loss of hair Hot flashes Weight gain Weight loss Mood swings Pain in muscles or joints Decreased interest in sex Inability or decreased ability to maintain an erection Signature of Patient Date Please complete this form and e-mail to [email protected] or fax to 561-370-6843.