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Have you had a comprehensive physical exam within the last 12 months?
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Have you had an EKG in the last 12 months?
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Past Medical History
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Past Medical History
• • •
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New Yes / No
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Past Surgical History
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Cardiac Event History
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Past Surgical History
• • •
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History of Cardiac Event
• • •
|
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Family HIstory
|
Family History
• • •
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Health and Lifestyle
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Health and Lifestyle
• • •
|
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Caffeine
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New Yes / No
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Amount of caffeine consumed
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Exercise
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How many times per week do you exercise?
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Type of Exercise
• • •
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Do you have any barriers to exercise?
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Barriers to Exercise
• • •
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Diet
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Are you Dieting?
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How many meals do you eat per day?
/
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Are you on a physician prescribed diet?
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Rate your salt intake
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Rate your fat intake
|
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Medications/Hormone Dietary Supplements
|
Are you currently taking hormones?
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Have you used Testosterone in the past?
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If yes, what kind?
• • •
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How long did you use them?
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Why did you stop them?
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Did you have any side effects?
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Do you take any Dietary Supplements?
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Do you have allergies to medications?
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Androgen Deficiency
|
Do you experience any of the following?
• • •
|
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Thyroid
|
Have you experienced any of the following?
• • •
|
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Sexual Function
|
Have you Experienced any of the Following?
• • •
|
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Taking any Medication Known to Cause Impotence?
|
Are you taking any of the Following Medication?
• • •
|
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Adrenal Fatigue
|
Have you experienced any of the following?
• • •
|
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Leaky Gut
|
Have you experienced any of the following?
• • •
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