Toll Free: (800) 991-6509 | Fax: (866) 902-8341

3701 E Thousand Oaks Blvd. Thousand Oaks, CA 91362

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Men - Health History



Date

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Personal Information


Name (*)

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Age

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Height

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Weight

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Birthdate

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Street Address

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City

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State

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Zip Code

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Email (*)

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Phone Number (*)

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Occupation

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What is your greatest need or problem? (List the most important; then list other issues in order of importance):

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Your current medical conditions or diagnoses:

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Drug allergies:

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Allergies to food, pollens, environment, etc:

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Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them:

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Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc): Other:

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Names of ALL vitamins, supplements, non-prescription medicines, or other OTC products that you are currently using:

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If you are you currently taking medication for a thyroid condition, which one and dose?

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Do you use tobacco products?

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For how long?

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Do you use alcohol products?

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How Much and How Long?

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Do you use caffeine products?

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What and How Much ?

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Do you use recreational drugs?

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What Recreational Drug and How Much?

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How much water do you drink in one day (24 hr)?

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Is your drinking water from a:

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Dietary Restrictions (such as salt, carbohydrates, milk products, red meat, etc):

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When was your last general medical exam:

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When was your last prostate exam:

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Were the results of your last prostate exam normal?

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If your doctor has recently ordered lab tests or diagnostic procedures for you, please give details, including whether the test or procedure was performed, and the results:

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Symptoms

CHECK A BOX FOR EACH SYMPTOM which best describes how you have been feeling for the past 3 weeks.

  • 0 = None (symptom not present)
  • 1 = Mild (present but not distressing)
  • 2 = Moderate (distressing, but not interfering with daily life)
  • 3 = Severe (very distressing, interferes with daily life)

If you wish to add comments or details, please send by separate email to our pharmacy, indicating your first and last name in the email. Thank you.



Decrease in muscle mass / strength / endurance
Decrease in self-confidence
Sleep disturbances
Irritability
Anxiety
Depression
Low energy
Forgetfulness
Difficulty concentrating
Inability to control anger
Rapid heart rate
Decrease in motivation
Headaches
Low libido
Joint pain



Men's Health Questions



Cholesterol test

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Cholesterol test date

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Cholesterol test abnormal?

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Sigmoidoscopy or colonoscopy

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Sigmoidoscopy or colonoscopy date

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Sigmoidoscopy or colonoscopy abnormal?

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In the past month, have you had little interest or pleasure in doing things, or felt down, depressed or hopeless?

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Personal Medical History

Please indicate whether you have had any of the following medical problems (with dates).



Heart disease / date / please specify type

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High blood pressure / date

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High cholesterol / date

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Diabetes / date

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Asthma/Lung disease / date

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Kidney disease / date

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Thyroid problem / date

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Cancer / date / please specify type

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3701 E Thousand Oaks Blvd. Thousand Oaks, CA 91362 | Toll Free: (800) 991-6509 | Fax: (866) 902-8341

DISCLAIMER

Paseo Oaks Pharmacy is a licensed compounding pharmacy that only engages in compounding in response to a physician's prescription. A written prescription from a licensed physician is required for compounded medication. The information on the site is general in nature and is only intended for use as an educational tool. You should consult your physician or a Paseo Oaks Pharmacy pharmacist if you have any specific questions relating to the diagnosis and treatment of any health problems. Information and statements about products and health conditions have not been evaluated by the Food and Drugs Administration (FDA), nor has the FDA approved the products to diagnose, cure or prevent disease.

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