Intake Form
NOTE!
You will be asked to provide detailed information about your health goals, body parameters, andropause, depression and anxiety symptoms, your medical and social history, and lifestyle. Filling out the form can take up to 15 minutes.
Please list (check) Diseases/Conditions YOU have/had.
Specify the type and/or time in the comments.
If not applicable, leave blank.
Alcoholism/Drug Abuse
Asthma
Emphysema (COPD)
Cancer
Depression
Anxiety
Bipolar
Suicidal
Epilepsy
Parkinson's Disease
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol
Thyroid Disease
Renal (kidney) Disease
Migraine/Headaches
Stroke
Trauma
✓
Disease/Condition
Comments
Please list ALL Surgeries you had.
If not applicable, leave blank.
Type
Date
Patient Health Questionnaire (PHQ-9)
For problems that do not apply, please mark “Not at all”.
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself
(feeling that you are a failure or have let yourself or your family down)
Trouble concentrating on things
(such as reading the newspaper or watching television)
Moving or speaking so slowly that other people could have noticed or the opposite – being so fidgety or restless that you have been moving around a lot more
Thoughts that you would be better off dead, or of hurting yourself in some way
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
Total score:
The implications of the scores are as follows:
-
5-9 minimal depression symptoms
-
10-14 mild depression symptoms
-
15-19 moderately severe depression symptoms
-
20-27 severe depression symptoms
Occupation (or prior occupation)
Occupational status
How many hours a week do you work?
Do you work the night shifts?
How many children do you have?
Are you planning any children in the future?
Social History
Tobbacco Use
Smoke Cigarettes?
Cigarettes/day
Number of years
Cigarettes/day
Number of years
Smoke Electronic Cigarettes?
Lifestyle Background
If you currently smoke:
If you don't smoke anymore, leave this blank.
If you smoked in the past:
If you still smoke, leave this blank.
Alcohol / Drug use
Do you drink alcohol?
Number of Drinks/week?
Do you use marijuana or recreational drugs?
Have you ever used needles to inject drugs?
Have you ever used a shared syringe to inject drugs?
Exercise
What kind of exercise?
Do you exercise regularly?
Duration? (hours/week)
How do you feel when you wake up in the morning?
How would you describe your diet?
What are you willing to change in your lifestyle to improve your well-being?
Is there anything you want to add about yourself, your health or lifestyle?
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Please fill in all required fields!
Please list (check) Diseases/Conditions YOUR RELATIVES have/had.
Tag a family member in the comments.
If not applicable, leave blank.
Alcoholism/Drug Abuse
Asthma
Emphysema (COPD)
Cancer
Depression
Anxiety
Bipolar
Suicidal
Epilepsy
Parkinson's Disease
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol
Thyroid Disease
Renal (kidney) Disease
Migraine/Headaches
Stroke
Trauma
✓
Disease/Condition
Comments
Sleep
How many hours do you sleep on average?
What time do you go to sleep?
How many times do you wake up on average during sleep?
Health Goals
WHR | Health risk |
|---|---|
0.95 or lower | Low |
0.96 - 1.0 | Moderate |
1.0 or higher | High |
WCR (optimal ) | 0.7 - 0.8 |
BMI | |
|---|---|
Under 18.5 | Underweight |
18.5 - 24.9 | Normal |
25 - 29.9 | Overweight |
30 and over | Obese |
Calculated Results
NOTE!
-
Blood pressure and pulse must be measured at rest.
-
Chest circumference should be measured at the level of the nipples.
-
Waist circumference should be measured at the level of the navel.
-
If you have had a DEXA/DXA scan within the last 6 months, please indicate your total body fat.
Body parameters
Aging Male Symptoms Score (AMS)
Which of the following symptoms apply to you AT THIS TIME?
For symptoms that do not apply, please mark “None”.
Decline in your feeling of general wellbeing
(general state of health, subjective feeling)
Joint pain and muscular ache
(lower limb, general back ache)
Excessive sweating
(unexpected/sudden episodes of sweating, hot flushes independent of strain)
Sleep problems
(difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)
Increased need for sleep, often feeling tired
Irritability
(feeling aggressive, easily upset about little things, low stress tolerance, moody)
Nervousness
(inner tension, restlessness)
Anxiety
(feeling panicky)
Physical exhaustion/lacking vitality
(general decrease in performance, reduced activity, feeling of getting less done, of having to force oneself to undertake activities)
Decrease in muscular strength
(feeling weak)
Depressive mood
(feeling down, sad, on the verge of tears, mood swings)
Feeling that you have passed your peak
Feeling burnt out, having hit rock-bottom
Decrease in beard growth
Decrease in the number of morning erections
Decrease in ability/frequency to perform sexualy
Decrease in sexual desire/libido
(lacking pleasure in sex, lacking desire for intercourse)
Total score:
The implications of the scores are as follows:
-
17-26 no significant symptoms consistent with a low testosterone level
-
27-36 mild symptoms consistent with a low testosterone level
-
37-49 moderate symptoms consistent with a low testosterone level
-
50-85 severe symptoms consistent with a low testosterone level
General Anxiety Disorder (GAD-7)
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it’s hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
Total score:
The implications of the scores are as follows:
-
0-4 minimal anxiety
-
5-9 mild anxiety
-
10-14 moderate anxiety
-
15-21 severe anxiety
Over the LAST 2 WEEKS, how often have you been bothered by any of
the following problems?
For problems that do not apply, please mark “Not at all”.
Allergic Reaction
Allergen
Please list ALL Allergens (medications, supplements, foods, etc.) that caused the Allergic Reaction.
If not applicable, leave blank.
Medical History
Please list ALL Medications and Supplements that you use AT THIS TIME.
If not applicable, leave blank.
Medications
Dose
(mg., pill, etc.)
Times Per Day or Week
(# TPD or # TPW)
Supplements
Dose
(mg., pill, etc.)
Times Per Day or Week
(# TPD or # TPW)