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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
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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
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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
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Do you experience any of the following?
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Thyroid
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Have you experienced any of the following?
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Sexual Function
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Have you Experienced any of the Following?
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Taking any Medication Known to Cause Impotence?
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Are you taking any of the Following Medication?
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Adrenal Fatigue
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Have you experienced any of the following?
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Gastrointestinal Concerns
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Have you experienced any of the following?
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Sexual Desire Questions
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Please check ALL the factors that you feel may be contributing to your current decrease in sexual desire or interest
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Gynecological History
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When was your last pap smear?
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When was your last mammogram?
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When was your last bone density scan?
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When was your last colonoscopy?
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Have you ever had an abnormal pap smear?
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Have you ever personally had any STIs?
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Fibroids?
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Endometriosis?
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Infertility?
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Urinary Incontinence?
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Contraceptive and Sexual History
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Present birth control method?
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Do you experience pain or discomfort with intercourse?
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Menstrual History
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First day of last menstrual period
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Number of the days the start of one period to the start of the next
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Number of days that you bleed
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Describe the amount of menstrual flow (light, Moderate, heavy)
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Describe the amount of menstrual discomfort (none, mild, moderate, severe)
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Do you bleed between periods?
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Do you bleed after intercourse?
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If you stopped menstruating, at which age did you stop?
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Have you ever had bleeding or spotting since your period stopped?
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