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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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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