Patient Questionnaire Giovane Medical Patient Questionnaire Step 1 of 6 16% About YouFirst Name(Required) First Last Name(Required) Last Sex Shipping Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Your Email Address(Required) Email Address Confirm Email Address Date of Birth MM slash DD slash YYYY Driver's License Number Referred by Family HistoryMother's AgeMother's Current Health Father's AgeFather's Current Health Brothers Ages Brothers Current Health Sisters Ages Sisters Current Health Children's Ages Children's Current Health Marital Status Single Married Separated Divorced Family Medical History*All fields of information are required in this sectionThyroid Disorder(Required) Yes No Endocrine Disorder(Required) Yes No Hypertension(Required) Yes No Lipid Disorder(Required) Yes No Cardiovascular Disease(Required) Yes No Prostate Cancer(Required) Yes No Diabetes(Required) Yes No Other Forms of Cancer(Required) Yes No Explain Yes Answers*(Required)*If not applicable, type NA or NONE Nutritional HistoryAre you a vegetarian? Yes No If you are a vegetarian, what food source do you rely on for protein in your diet? What is your typical Breakfast? What is your typical Morning Snack? What is your typical Lunch? What is your typical Afternoon Snack? What is your typical Dinner? What is your typical Evening Snack? Please list the specific Vitamins and other supplements you currently take:Work HistoryWhat is your occupation? How long in this position?*in yearsAre you happy with your present employment? Yes No If no, please explain Do you travel frequently? Yes No Please rate the stress level of your job Low Moderate High Exercise HistoryDo you have a gym membership? Yes No If so, Where? Do you have a personal trainer? Yes No Do you? Run Jog Fast Walk Do you compete in organized sports? Yes No What kind of exercises do you enjoy? (Check any that apply) Group Aerobics Weight Training Swimming Cycling Rollerblading Climbing Hiking Tennis Golf Other Personal HistoryPlease rate the level of stress in your home: Low Moderate High What do you do for relaxation or stress reduction? Would you describe yourself as (Check as many that apply) Happy Content Just Making It Struggling Depressed Energetic Physically Fit Out of Shape Just Plain Worn Out A Natural Leader A Team Player Work Best in a Structured Environment A Victim Medical HistoryHeight WeightWeight One Year AgoWeight you would like to beSurgeries you have had: Current Medications Add RemoveMedications or foods you are ALLERGIC to: Name and Location of your Primary Physician: Treatments you have recieved fo illnesses or injuries in the last year:Do you smoke or chew tobacco? Yes No How Much? How Long? Do you drink alcoholic beverages? Yes No How Much? In what form? Your general health today is: Excellent Good Fair Poor *All fields of informaion are required in this section1. Carpal Tunnel Syndrome?(Required) Yes No 2. Blood Disorder(Required) Yes No 3. Cancer(Required) Yes No 4. Immune Disorders(Required) Yes No 5. Poor Wound Healing(Required) Yes No 6. Edema/excess fluid retention(Required) Yes No 7. Hyperlipidemia or an elevation of lipids in the bloodstream.(Required) Yes No *These lipids include cholesterol and triglycerides8. Upper Respiratory(Required) Yes No 9. Lung Disorder(Required) Yes No 10. Hypertension(Required) Yes No 11. Are you taking Nitrates?(Required) Yes No 12. Renal Disease(Required) Yes No *Renal failure is the condition in which the kidneys fail to function properly13. Emotional Disorders(Required) Yes No 14. Genital-Urinary Disorder(Required) Yes No 15. Glaucoma(Required) Yes No Please Explain Yes Answers:(Required) SELF EVALUATION OF AGING BIOMARKERS*Please check the appropriate boxes that best describe your current functional levels.Mental Functions:1. Spells of mental fatigue, inability to concentrate; feeling burned out: Not Me! Moderate Often 2. Tired or sleepy in the afternoon or early evening: Not Me! Moderate Often 3. Less mentally sharp, limited attention, not as witty: Not Me! Moderate Often 4. Change in creativity or spontaneous new ideas: Not Me! Moderate Often 5. Decrease in initiative to start new projects: Not Me! Moderate Often 6. Decrease in interest in past hobbies or new work-related activities: Not Me! Moderate Often 7. Decrease in competitiveness: Not Me! Moderate Often 8. Change in memory function; increased forgetfulness: Not Me! Moderate Often 9. Feelings of depression; a sense that work, marriage, or Recreational activities have lost significance: Not Me! Moderate Often Metabolic Functions:10. Unexplained weight gain, particularly in the midsection: Not Me! Moderate Often 11. Increased fat distribution in hips or breast area: Not Me! Moderate Often 12. Increase in cholesterol or triglycerides: Not Me! Moderate Often 13. Decrease in HDL cholesterol: Not Me! Moderate Often 14. Rise in blood sugar levels or onset of diabetes: Not Me! Moderate Often 15. Rise in blood pressure or diagnosed as "hypertensive": Not Me! Moderate Often 16. Chest pain, diagnosis of "heart disease" or "blockage in arteries": Not Me! Moderate Often 17. Shortness of breath with activity, asthma or emphysema: Not Me! Moderate Often 18. Lightheadedness, dizzy spells, ringing in the ears, new headaches: Not Me! Moderate Often 19. Poor circulation in legs, swelling of ankles, varicose veins, Hemorrhoids: Not Me! Moderate Often Physical Conditioning:20. "Sore body syndrome", aches, joint and muscle pains: Not Me! Moderate Often 21. Decline in flexibility and mobility; increased stiffness: Not Me! Moderate Often 22. Decrease in muscle size, tone, strength: Not Me! Moderate Often 23. Decrease in physical stamina: Not Me! Moderate Often 24. Decrease in athletic performance: Not Me! Moderate Often 25. Back pain, neck pain: Not Me! Moderate Often 26. Tendency to pull muscles or get leg cramps: Not Me! Moderate Often 27. Development of osteoporosis or inflammatory arthritis: Not Me! Moderate Often Sexual Functions (Men)28. Decreased libido or desire for sex: Not Me! Moderate Often 29. Decrease in spontaneous early morning erections: Not Me! Moderate Often 30. Difficulty in maintaining a full erection: Not Me! Moderate Often 31. Decrease in volume of ejaculate or semen: Not Me! Moderate Often Sexual Functions (Women)32. Decreased libido or desire for sex: Not Me! Moderate Often 33. Vaginal Dryness: Not Me! Moderate Often 34. Vaginal Atrophy (Shrinking of Tissues): Not Me! Moderate Often Giovane Medical Services IncorporatedCONSENT FOR HORMONE REPLACEMENT THERAPY(Required)By signing this CONSENT, you agree that Physical Male and Their affiliates have your permission to manage your program of longevity medicine, utilizing nutritional guidance, exercise programs, natural supplements and hormone replacement therapy as deemed necessary. All therapeutic procedures involve some risk, including failure to receive the desired result or to obtain the information sought. Although your doctor is the best source of information as to the risks involved, Physical Male is a partnership between doctor and patient which requires you to accept designated responsibility for carrying out your part of the program. Please be sure that you receive or request full information before signing this form. You are entitled to be fully informed by your doctor about the nature of the therapy, it’s purpose, it’s anticipated benefits, possible side effects, available alternatives, independent economic interests of your doctor, if any, and all known or reasonably foreseeable risks involved. Your signature on this CONSENT means: (1) You have read and understand the information contained herein; (2) you will be informed by your physician about the nature and risks of this therapy; (3) you will be provided with an opportunity by your physician to ask questions about the nature and risks; (4) you have received all the information you desire about this therapy; and (5) you consent to the hormone replacement therapy program. I agree to the privacy policy.Print Name(Required) First Print Name(Required) Last Today's Date(Required) MM slash DD slash YYYY Time(Required) Hours : Minutes AM PM AM/PM
