Name:

Date of Birth:

Address:

City/Town:                                                      State:                                       Postcode:

Tel no:                                                                                   Mobile:

Email Address:

Occupation:                                                                   Height:                                          Weight:

Your Doctor’s Name:

Address;

Do you Smoke:                                      How often and How much:

Did you ever smoke:                                 When did you give up:

Do you drink Alcohol:                            How often and How much:

Do you have any allergies:

Marital Status:                                    What Work do you do:

What operations have you had:

Major illnesses or Diseases:

What medicines are you on:

Family history: Any important illness/diseases in the family:

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Hormone Checklist:

Symptom                                 None      Mild     Moderate    Severe

Loss of Motivation (Drive)

Loss of Sex Drive

Irritable

Anxiety level

Depression

Problems handling stress

Fatigue

Needs Daytime sleep

Frequency of spontaneous erections

Reduced frequency intercourse

Loss of muscle tone

Increased belly/Breast size

Loss of competitiveness

Loss of interest in exercise/sport

Loss of body hair

Skin becoming fine/frail

Loss of height

Falling asleep in front of Telly

Prostate problem.

Print this out and bring it with you when seeing Dr Holloway

Do the next 2 as well, print and bring in with you.

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