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For CLINIC visits, click this button
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For TO GO visits, click this button
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Reasons for Visit
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High Blood Pressure
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Hangover? Please check ALL that apply
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Diabetes
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Dehydration
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Sinus Congestion/Upper Resp Infxn
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Fatigue
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Flu
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Headache
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Thyroid Disorder
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Nausea or Vomiting
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Overweight/Obesity
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Muscle Aches/Pain
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Diarrhea
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Pain level Scale (1-10)
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History of heart disease?
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Are you of Mediterranean Descent?
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Ever had Abnormal EKG? Stress test?
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History of Depression?
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History of Lung Disease (COPD?)
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High Cholesterol?
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Kidney Disease/Abnormal BUN/Cr?
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Anemia?
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Asthma?
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Other medical history not mentioned?
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Turn on to fill out FEMALE QUESTIONNAIRE
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Turn on to fill out MALE QUESTIONNAIRE
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Symptom
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Depressive Mood
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Memory Loss
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Mental Confusion
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Decreased sex drive / libido
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Sleep Problems
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Mood changes / Irritability
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Tension
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Migraine / severe headaches
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Difficult to climax sexually
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Bloating
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Weight gain
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Breast tenderness
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Vaginal dryness
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Hot flashes
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Night sweats
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Dry and wrinkled skin
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Hair is Falling Out
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Cold all the time
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Swelling all over the body
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Joint pain
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Other symptoms that concern you:
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Symptom
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Decline in general well being
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Joint pain / Muscle ache
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Excessive sweating
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Sleep problems
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Increased need for sleep
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Irritability
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Nervousness
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Anxiety
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Depressed mood
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Exhaustion / lacking vitality
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Declining Mental Ability / Focus / Concentration
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Feeling you have passed your peek
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Feeling burned out / hit rock bottom
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Decreased muscle strength
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Weight Gain/ Belly Fat/ Inability to Lose Weight
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Breast Developement
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Shrinking Testicles
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Rapid Hair Loss
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Decrease in beard growth
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New Migraine Headaches
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Decreased desire / libido
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Decreased morning erections
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Decreased ability to perform sexually
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Infrequent or Absent Ejaculations
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No Results from E.D. Medications
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Other symptoms that concern you:
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History of heart disease?
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Are you of Mediterranean Descent?
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Ever had Abnormal EKG? Stress test?
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History of Lung Disease (COPD?)
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Kidney Disease/Abnormal BUN/Cr?
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History of Liver Disease?
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