Male Natural Hormone Evaluation

This Free Male Hormone Evaluation allows you to inform our Compounding

Pharmacist about all of your current symptoms and past medical history.

Please note that all information is confidential and is not released to other

health care professionals without your authorization.  After receiving your

evaluation we will contact you via e-mail or phone to see if you would like

a Bio-Identical "Natural" Hormone Replacement consultation with our Chief

Compounding Pharmacist, Dr. Mark A. Gonzalez or one of his associates.

Although the evaluation is free. a consultation with our pharmacist is

subject to a consultation fee.

Please make sure to click on the submit button at the end of the hormone

evaluation to ensure proper transmission of your data.

General Information  ("*" Indicates Required Information)

Name*: DOB*:

Address: City:

Zip:   State:*

Home Phone*:   Work Phone:

Fax:     E-Mail*:

Occupation: Work Hours Per Week:

Marital Status: Single    Married    Divorced    Widowed

How Did You Hear About Natural Hormone Replacement?

Do You Understand The Difference Between Natural & Synthetic Hormones?

What Are Your Goals For Natural Hormone Replacement?

Health Care Provider: Full Name

Address: City:

Phone Number:   Fax:

General Health: Excellent    Good    Fair    Poor   

Height   Weight

Current Diagnosis Or Medical Conditions:

Drug Allergies:   Food Allergies:

Current Medications, Dose, And Duration Of Treatment:

Current Vitamins/Herbs, Dose, And Duration Of Treatment:

Medical Status:   

Cholesterol Date     Blood Pressure Date

Blood Glucose Date

Have You Ever Had A Bone Density Scan:  Yes  No    Date

List All Past Medical Conditions:

Dietary And Social Information:

Breakfast Foods:    

Lunch Foods:     

Dinner Foods:        

Snack Foods:    

Do You Drink? Yes  No    If yes, what and how often:

Do You Smoke? Yes  No  If yes, what and how often:

Do You Use Drugs? Yes  No  What and how often:    

Do You Exercise?  Yes  No   If yes, please explain:     

Family Medical History:

Father Living  Deceased  Age Medical History

Mother Living  Deceased  Age  Medical History

Sibling  Living  Deceased  Age  Medical History

Sibling  Living  Deceased  Age  Medical History

Sibling  Living  Deceased  Age  Medical History

List Of Symptoms

Sexual Function

Decrease in spontaneous morning erection:

Absent    Mild    Moderate    Severe

Decreased libido or desire for sex:

Absent    Mild    Moderate    Severe

Decrease in fullness of erections:

Absent    Mild    Moderate    Severe

Decrease in volume of ejaculate or semen:

Absent    Mild    Moderate    Severe

Decrease in strength of climax or force of muscular pulsations:

Absent    Mild    Moderate    Severe

Decrease in maintaining full erection:

Absent    Mild    Moderate    Severe

Difficulty in starting erection - or no erection:

Absent    Mild    Moderate    Severe

If you have experienced changes in sexual function recently please describe them below:

Mental Function

Spells of mental fatigue or inability to concentrate; burned out:

Absent    Mild    Moderate    Severe

Tiredness or sleepiness in the afternoon or early evening:

Absent    Mild    Moderate    Severe

Decrease in mental sharpness, attention, wit:

Absent    Mild    Moderate    Severe

Change in creativity or spontaneous new ideas:

Absent    Mild    Moderate    Severe

Decrease in initiative or desire to start new projects:

Absent    Mild    Moderate    Severe

Decreased interest in hobbies or new work related activities:

Absent    Mild    Moderate    Severe

Decreased competitiveness:

Absent    Mild    Moderate    Severe

 Change in memory function; increased forgetfulness:

Absent    Mild    Moderate    Severe

Feeling of depression; a sense that work, marriage, or recreational activities have lost significance:

Absent    Mild    Moderate    Severe

Musculoskeletal Condition

"Sore-body syndrome" - aches, joint, and muscle pains:

Absent    Mild    Moderate    Severe

Decline in flexibility and mobility; increased stiffness:

Absent    Mild    Moderate    Severe

Decrease in muscle size, tone, strength:

Absent    Mild    Moderate    Severe

Decrease in physical stamina:

Absent    Mild    Moderate    Severe

Decrease in athletic performance:

Absent    Mild    Moderate    Severe

Back pain; neck pain:

Absent    Mild    Moderate    Severe

Tendency to pull muscles or get leg cramps:

Absent    Mild    Moderate    Severe

Development of osteoporosis or inflammatory arthritis:

Absent    Mild    Moderate    Severe

Physical Disease Problems

Increase in total cholesterol or triglycerides:

Absent    Mild    Moderate    Severe

Decrease in HDL cholesterol:

Absent    Mild    Moderate    Severe

Rise in blood sugar level or diabetes onset:

Absent    Mild    Moderate    Severe

Rise in blood pressure/diagnosis or hypertension:

Absent    Mild    Moderate    Severe

Unexplained weight gain, particularly in the midsection:

Absent    Mild    Moderate    Severe

Increased fat distribution in breast area or hips:

Absent    Mild    Moderate    Severe

Development of chest pain, or diagnosis of heart disease:

Absent    Mild    Moderate    Severe

Shortness of breath with activities/worsening of asthma:

Absent    Mild    Moderate    Severe

Lightheadedness, dizzy spells, or ringing of ears:

Absent    Mild    Moderate    Severe

New onset of headaches:

Absent    Mild    Moderate    Severe

Poor circulation in legs, swelling of ankles, developed hemorrhoids:

Absent    Mild    Moderate    Severe

Changes in visual acuity, focus reading fine print:

Absent    Mild    Moderate    Severe

How old to you feel?

Please write down any additional information you would wish to provide below?

Would you like to have our office call you for a private and personal hormone evaluation with a compounding pharmacist specializing in Natural "Bio-Identical" Hormone Replacement?

Yes   No

What time of the day would you like us to contact you?

Morning   Afternoon  Evening

What specific questions do you have for our Hormone Specialist? Our FREE response will be e-mailed back to you in a timely manner.

Would you like a FREE recommendation on which hormones to have tested based on the information provided in this evaluation?

Yes        No

CLICK HERE TO SUBMIT DATA       

This free bio-identical hormone replacement evaluation is provided by

TestMyHormones.com.  All data and information collected is considered

confidential and will not be distributed without patent consent.