Diabetes, thyroid or other
Other forms of cancer
Do You Smoke?
If Yes how much do you smoke per day?
Do you drink alcohol?
If Yes how much do you drink per week?
Are you taking over the counter supplements?
Do you exercise regularly?
If Yes, please describe:
Any known deficiency including minerals and electrolytes
Use of medications:
(if yes, list medications below)
Carpal Tunnel syndrome
Orthopedic or muscle disorder including fracture
or joint disorders
Heart disease including Atherosclerosis, Angina,
Heart Failure, Heart Attack
Allergies to Medications
Edema / excess fluid retention
Poor wound healing
Emotional disorders / depression
Genital – Urinary disorder
Neurological disorders, Thyroid, Diabetes or other
endocrine disorder including insulin resistance,
Prior history of Steroids or hormones?
Type / Dose / Frequency
Prior Medical Records / Labs?
Decreased desire and ability to exercise
Increasing sagging muscles or breasts:
Cold or heat intolerance
Decreased energy or endurance
Decreased sense of well-being
Decreasing size of testicals
Loss of interest in sex
Decreasing muscle strength
Loss of concentration, sociability, activity
Progressive osteoporosis, decreasing bone mass or
Sagging, loose or thin skin
Thinning or loss of hair
Increased lack of drive
Increasing fat deposits about abdomen and/or thighs
Weight loss – Unexplained
Increasing mood swings
Sore Muscles, join pain(s) or swelling?
Please use this space to explain
“other” and write any additional information: