Male Intake Questionnaire

    General Information

    Today’s Date
    Date of Birth
    Genetic Background:
    When, where and from whom did you last receive medical or health care?
    How did you hear about our practice?

    Current Health Concerns

    Please rank current and ongoing health concerns in order of priority
    Severity Success
    Severity Success
    Severity Success
    Severity Success
    Severity Success
    Severity Success
    Severity Success
    Severity Success
    Severity Success
    Severity Success
    Allergies

    Lifestyle Review

    Sleep
    Do you have problems falling asleep?
    Do you have problems with insomnia?
    Do you feel rested upon awakening?
    Do you use sleeping aids?
    Staying asleep?
    Do you snore?
    Exercise Current Exercise Program:
    Activity: Cardio/Aerobic
    Activity: Strength/Resistance
    Activity: Flexibility/Stretching
    Activity: Balance
    Activity: Sports/Leisure (e.g., golf)
    Activity: Other
    Do you feel motivated to exercise?
    Are there any problems that limit exercise?
    Do you feel unusually fatigued or sore after exercise?
    Nutrition Do you currently follow any of the following special diets or nutritional programs? (Check all that apply)
    Do you have sensitivities to certain foods?
    Do you have an aversion to certain foods?
    Do you adversely react to: (Check all that apply)
    Are there any foods that you crave or binge on?
    Do you eat 3 meals a day?
    Does skipping a meal greatly affect you?
    How many meals do you eat out per week?
    Check the factors that apply to your current lifestyle and eating habits:
    Diet Please record what you eat in a typical day:
    How many servings do you eat in a typical week of these foods:
    Fruits (not juice)
    Legumes (beans, peas, etc)
    Dairy/Alternatives
    Cans of soda (regular or diet)
    Vegetables (not including white potatoes)
    Red meat
    Fish
    Nuts & Seeds
    Fats & Oils
    Sweets (candy, cookies, cake, ice cream, etc.)
    Do you drink caffeinated beverages?
    If yes, check amounts:
    Coffee (cups per day)
    Tea (cups per day)
    Caffeinated sodas—regular or diet (cans per day)
    Do you have adverse reactions to caffeine?
    If yes, explain: When you drink caffeine do you feel:
    Smoking Do you smoke currently?
    What type?
    Have you attempted to quit?
    If you smoked previously:
    Are you regularly exposed to second-hand smoke?
    Alcohol How many alcoholic beverages do you drink in a week? (1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits)
    Previous alcohol intake?
    Have you ever had a problem with alcohol?
    Have you ever thought about getting help to control or stop your drinking?
    Other Substances Are you currently using any recreational drugs? Have you ever used IV or inhaled recreational drugs?
    Stress Do you feel you have an excessive amount of stress in your life?
    Do you feel you can easily handle the stress in your life?
    How much stress do each of the following cause on a daily basis (Rate on scale of 1-10, 10 being highest)
    Do you use relaxation techniques?
    Which techniques do you use? (Check all that apply)
    Have you ever sought counseling?
    Are you currently in therapy?
    Have you ever been abused, a victim of crime, or experienced a significant trauma?
    Relationships Marital status:
    Do you have resources for emotional support?
    (Check all that apply) Do you have a religious or spiritual practice? How well have things been going for you? (Mark on scale of 1–10, or N/A if not applicable)
    Overall
    At school
    In your job
    In your social life
    With close friends
    With sex
    With your attitude
    With your boyfriend/girlfriend
    With your children
    With your parents
    With your spouse

    History

    Patient’s Birth/Childhood History: You were born:
    Were there any pregnancy or birth complications?
    You were:

    Age of introduction of: As a child, were there any foods that were avoided because they gave you symptoms? Did you eat a lot of sugar or candy as a child?
    Dental History: Check if you have any of the following, and provide number if applicable:
    Have you had any mercury fillings removed? Do you brush regularly? Do you floss regularly? Environmental/Detoxification History Do any of these significantly affect you? In your work or home environment are you regularly exposed to: (Check all that apply) Have you had a significant exposure to any harmful chemicals?
    Do you have any pets or farm animals?
    Men's History (Check box if applicable)
    Men’s History (cont.) Screening/Procedures: (If applicable, provide date)
    PSA Level:

    Family History:

    Check family members that have/had any of the following Age (if still alive)
    Age at death (if deceased)
    Cancer

    Heart disease

    Hypertension

    Obesity

    Diabetes

    Stroke

    Autoimmune disease

    Arthritis

    Kidney disease

    Thyroid problems

    Seizures/epilepsy

    Psychiatric disorders

    Anxiety

    Depression

    Asthma

    Allergies

    Eczema

    ADHD

    Autism

    Irritable Bowel Syndrome

    Dementia

    Substance abuse

    Genetic disorders

    Other

    Medical History: Illnesses/Conditions

    Check YES = a condition you currently have ,
    Check PAST = a condition you’ve had in the past.
    Gastrointestinal
    Irritable bowel syndrome
    GERD (reflux)
    Crohn’s disease/ulcerative colitis
    Peptic ulcer disease
    Celiac disease
    Gallstones
    Other
    Respiratory
    Bronchitis
    Asthma
    Emphysema
    Pneumonia
    Sinusitis
    Sleep apnea
    Other
    Urinary/Genital
    Kidney stones
    Gout
    Interstitial cystitis
    Frequent yeast infections
    Frequent urinary tract infections
    Sexual dysfunction
    Sexually transmitted diseases
    Other
    Endocrine/Metabolic
    Diabetes
    Hypothyroidism (low thyroid)
    Hyperthyroidism (overactive thyroid)
    Infertility
    Metabolic syndrome/insulin resistance
    Eating disorder
    Hypoglycemia
    Other
    Inflammatory/Immune
    Rheumatoid arthritis
    Chronic fatigue syndrome
    Food allergies
    Environmental allergies
    Multiple chemical sensitivities
    Autoimmune disease
    Immune deficiency
    Mononucleosis
    Hepatitis
    Other
    Musculoskeletal
    Fibromyalgia
    Osteoarthritis
    Chronic pain
    Other
    Skin
    Eczema
    Psoriasis
    Acne
    Skin cancer
    Other
    Cardiovascular
    Angina
    Heart attack
    Heart failure
    Hypertension (high blood pressure)
    Stroke
    High blood fats (cholesterol, triglycerides)
    Rheumatic fever
    Arrythmia (irregular heart rate)
    Murmur
    Mitral valve prolapse
    Other
    Neurologic/Emotional
    Epilepsy/Seizures
    ADD/ADHD
    Headaches
    Migraines
    Depression
    Anxiety
    Autism
    Multiple sclerosis
    Parkinson’s disease
    Dementia
    Other
    Cancer
    Lung
    Breast
    Colon
    Ovarian
    Skin
    Other
    Medical History (cont.)
    Diagnostic Studies (Bone density)
    Date
    Comments
    Diagnostic Studies (CT scan)
    Date
    Comments
    Diagnostic Studies (Colonoscopy)
    Date
    Comments
    Diagnostic Studies (Cardiac stress test)
    Date
    Comments
    Diagnostic Studies (EKG)
    Date
    Comments
    Diagnostic Studies (Upper endoscopy)
    Date
    Comments
    Diagnostic Studies (Upper GI series)
    Date
    Comments
    Diagnostic Studies (Chest X-ray)
    Date
    Comments
    Diagnostic Studies (Other X-rays)
    Date
    Comments
    Diagnostic Studies (Barium enema)
    Date
    Comments
    Diagnostic Studies (Other)
    Date
    Comments
    Injuries (Broken bone(s))
    Date
    Comments
    Injuries (Back injury)
    Date
    Comments
    Injuries (Neck injury)
    Date
    Comments
    Injuries (Head injury)
    Date
    Comments
    Injuries (Other)
    Date
    Comments
    Surgeries (Appendectomy)
    Date
    Comments
    Surgeries (Dental)
    Date
    Comments
    Surgeries (Gallbladder)
    Date
    Comments
    Surgeries (Hernia)
    Date
    Comments
    Surgeries (Tonsillectomy)
    Date
    Comments
    Surgeries (Joint replacement)
    Date
    Comments
    Surgeries (Heart surgery)
    Date
    Comments
    Surgeries (Other)
    Date
    Comments
    Hospitalizations ()
    Date
    Comments
    Hospitalizations ()
    Date
    Comments
    Hospitalizations ()
    Date
    Comments
    Hospitalizations ()
    Date
    Comments
    Hospitalizations ()
    Date
    Comments
    Hospitalizations ()
    Date
    Comments

    Symptom Review

    Please check if these symptoms occur presently or have occurred in the last 6 months
    General
    Cold hands and feet
    Cold intolerance
    Daytime sleepiness
    Difficulty falling asleep
    Early waking
    Fatigue
    Fever
    Flushing
    Heat intolerance
    Night waking
    Nightmares
    Can’t remember dreams
    Low body temperature
    Head, Eyes, and Ears
    Conjunctivitis
    Distorted sense of smell
    Distorted taste
    Ear fullness
    Ear ringing/buzzing
    Eye crusting
    Eye pain
    Eyelid margin redness
    Headache
    Hearing loss
    Hearing problems
    Migraine
    Sensitivity to loud noises
    Vision problems
    Musculoskeletal
    Back muscle spasm
    Calf cramps
    Chest tightness
    Foot cramps
    Joint deformity
    Joint pain
    Joint redness
    Joint stiffness
    Muscle pain
    Muscle spasms
    Muscle stiffness
    Muscle twitches:
    Around eyes
    Arms or legs
    Muscle weakness
    Musculoskeletal (cont.)
    Neck muscle spasm
    Tendonitis
    Tension headache
    TMJ problems
    Mood/Nerves
    Agoraphobia
    Anxiety
    Auditory hallucinations
    Blackouts
    Depression
    Difficulty
    Concentrating
    With balance
    With thinking
    With judgment
    With speech
    With memory
    Dizziness (spinning)
    Fainting
    Fearfulness
    Irritability
    Light-headedness
    Numbness
    Other phobias
    Panic attacks
    Paranoia
    Seizures
    Suicidal thoughts
    Tingling
    Tremor/trembling
    Visual hallucinations
    Cardiovascular
    Angina/chest pain
    Breathlessness
    Heart attack
    Heart murmur
    High blood pressure
    Irregular pulse
    Mitral valve prolapse
    Palpitations
    Phlebitis
    Swollen ankles/feet
    Varicose veins

    Symptom Review (cont.)

    Please checkif these symptoms occur presently or have occurred in the last 6 months
    Urinary
    Bed wetting
    Hesitancy
    Infection
    Kidney disease
    Kidney stone
    Leaking/incontinence
    Pain/burning
    Prostate enlargement
    Prostate infection
    Urgency
    Digestion
    Anal spasms
    Bad teeth
    Bleeding gums
    Bloating of:
    Lower abdomen
    Whole abdomen
    Bloating after meals
    Blood in stools
    Burping
    Canker sores
    Cold sores
    Constipation
    Cracking at corner of lips
    Dentures w/poor chewing
    Diarrhea
    Difficulty swallowing
    Dry mouth
    Farting
    Fissures
    Foods "repeat" (reflux)
    Heartburn
    Hemorrhoids
    Intolerance to:
    Lactose
    All dairy products
    Gluten (wheat)
    Corn
    Eggs
    Fatty foods
    Yeast
    Liver disease/jaundice (yellow eyes or skin)
    Digestion (cont.)
    Lower abdominal pain
    Mucus in stools
    Nausea
    Periodontal disease
    Sore tongue
    Strong stool odor
    Undigested food in stools
    Upper abdominal pain
    Vomiting
    Eating
    Binge eating
    Bulimia
    Can't gain weight
    Can't lose weight
    Carbohydrate craving
    Carbohydrate intolerance
    Poor appetite
    Salt cravings
    Frequent dieting
    Sweet cravings
    Caffeine dependency
    Respiratory
    Bad breath
    Bad odor in nose
    Cough – dry
    Cough – productive
    Hayfever:
    Spring
    Summer
    Fall
    Change of season
    Hoarseness
    Nasal stuffiness
    Nose bleeds
    Post nasal drip
    Sinus fullness
    Sinus infection
    Snoring
    Sore throat
    Wheezing
    Winter stuffiness

    Symptom Review (cont.)

    Please check if these symptoms occur presently or have occurred in the last 6 months
    Nails
    Bitten
    Brittle
    Curve up
    Frayed
    Fungus – fingers
    Fungus – toes
    Pitting
    Ragged cuticles
    Ridges
    Soft
    Thickening of:
    Finger nails
    Toenails
    White spots/lines
    Lymph Nodes
    Enlarged/neck
    Tender/neck
    Other enlarged/tender
    lymph nodes
    Skin, Dryness of
    Eyes
    Feet
    Any cracking?
    Any peeling?
    Hair
    And unmanageable?
    Hands
    Any cracking?
    Any peeling?
    Mouth/throat
    Scalp
    Any dandruff?
    Skin in general
    Skin Problems
    Acne on back
    Acne on chest
    Acne on face
    Acne on shoulders
    Athlete’s foot
    Bumps on back of upper arms
    Cellulite
    Dark circles under eyes
    Skin Problems (cont.)
    Ears get red
    Easy bruising
    Eczema
    Herpes – genital
    Hives
    Jock itch
    Lackluster skin
    Moles w color/size change
    Oily skin
    Pale skin
    Patchy dullness
    Psoriasis
    Rash
    Red face
    Sensitive to bites
    Sensitive to poison ivy/oak
    Shingles
    Skin cancer
    Skin darkening
    Strong body odor
    Thick calluses
    Vitiligo
    Itching Skin
    Anus
    Arms
    Ear canals
    Eyes
    Feet
    Hands
    Legs
    Nipples
    Nose
    Genitals
    Roof of mouth
    Scalp
    Skin in general
    Throat
    Male Reproductive
    Discharge from penis
    Ejaculation problem
    Genital pain
    Impotence
    Infection
    Lumps in testicles
    Poor libido (low sex drive)

    Medications/Supplements

    Current medications (include prescription and over-the-counter)
    Medication
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Medication
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Medication
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Medication
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Medication
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Medication
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Medication
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Medication
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Nutritional supplements (vitamins/minerals/herbs etc.)
    Name and Brand
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Name and Brand
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Name and Brand
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Name and Brand
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Name and Brand
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Name and Brand
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Name and Brand
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Name and Brand
    Dosage
    Start Date (mo/yr)
    Reason for Use
    Have medications or supplements ever caused unusual side effects or problems? Have you used any of these regularly or for a long time: NSAIDs (Advil, Aleve, etc.), Motrin, Aspirin? Tylenol (acetaminophen)? Acid-blocking drugs (Zantac, Prilosec, Nexium, etc.)?
    How many times have you taken antibiotics?
    Infancy/Childhood
    Teen
    Adulthood
    Have you ever taken long term antibiotics?
    How often have you taken oral steroids (e.g., cortisone, prednisone, etc.)?
    Infancy/Childhood
    Teen
    Adulthood

    Readiness Assessment and Health Goals

    Readiness Assessment
    Rate on a scale of 5 (very willing) to 1 (not willing): In order to improve your health, how willing are you to: Significantly modify your diet Take several nutritional supplements each day Keep a record of everything you eat each day Modify your lifestyle (e.g., work demands, sleep habits Practice a relaxation technique Engage in regular exercise Rate on a scale of 5 (very confident) to 1 (not confident at all): How confident are you of your ability to organize and follow through on the above health-related activities? Rate on a scale of 5 (very supportive) to 1 (very unsupportive): At the present time, how supportive do you think the people in your household will be to your implementing the above changes? Rate on a scale of 5 (very frequent contact) to 1 (very infrequent contact): How much ongoing support (e.g., telephone consults, email correspondence) from our professional staff would be helpful to you as you implement your personal health program?

    Health Goals