Men's Consultation Form

Date Date / MM / DD YYYY
Personal Information
Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Height
Weight
Birthdate Birthdate / MM / DD YYYY
BMI (Pharmacist will calculate - BMI = Weight in kg/Height in meters2)
BMI Results for Adults Over 35:

19-26.9 Recommended
27-29.9 Overweight
30-39.9 Obese
40 (+) Morbidly Obese
Waist Circumference
Waist:Hip Ratio (waist/hip)
Medical & Social History: Please check the following that apply to you.

Medical & Social History: Please check the following that apply to you. High Blood Pressure High Cholesterol Cardiovascular Disease Diabetes Mellitus Osteoporosis Benign Prostatic Hyperplasia Tobacco Use Asthma/COPD Alcohol Use Erectile Dysfunction Insomnia Malnutrition Depression Cancer Other
If you checked Cancer, please explain.
If you checked Other, please explain.
Medication History: List all prescription and non-prescription medications that you are taking. (Include vitamins, herbals and supplements.)
Drug Allergies
Do you feel more fatigued and/or tired than usual?

Do you feel more fatigued and/or tired than usual? Not Applicable Mild Moderate Severe
Have you noticed a decrease in your muscle mass?

Have you noticed a decrease in your muscle mass? Not Applicable Mild Moderate Severe
Have you experienced an increase in joint and/or muscle pains?

Have you experienced an increase in joint and/or muscle pains? Not Applicable Mild Moderate Severe
Have you noticed an increase in your waist size?

Have you noticed an increase in your waist size? Not Applicable Mild Moderate Severe
Do you have trouble losing weight?

Do you have trouble losing weight? Not Applicable Mild Moderate Severe
Have you experienced a loss in height?

Have you experienced a loss in height? Not Applicable Mild Moderate Severe
Do you have a decrease in your sex drive?

Do you have a decrease in your sex drive? Not Applicable Mild Moderate Severe
Have you experienced difficulty in establishing and/or maintaining
full erections?

Have you experienced difficulty in establishing and/or maintaining
full erections? Not Applicable Mild Moderate Severe
Do you have a decrease in spontaneous early morning erections?

Do you have a decrease in spontaneous early morning erections? Not Applicable Mild Moderate Severe
Have you experienced changes in your usual sleep pattern?

Have you experienced changes in your usual sleep pattern? Not Applicable Mild Moderate Severe
Do you feel a decrease in your mental sharpness?

Do you feel a decrease in your mental sharpness? Not Applicable Mild Moderate Severe
Have you had trouble concentrating?

Have you had trouble concentrating? Not Applicable Mild Moderate Severe
Do you experience less enjoyment in personal interests and hobbies?

Do you experience less enjoyment in personal interests and hobbies? Not Applicable Mild Moderate Severe
I am ________ years old
I feel ________ years old
I acknowledge that I am submitting my health information to initiate a consultation with the pharmacist. I understand that although the most secure transmission methods are used, security cannot be 100% guaranteed.

I acknowledge that I am submitting my health information to initiate a consultation with the pharmacist. I understand that although the most secure transmission methods are used, security cannot be 100% guaranteed. Yes

Men's Consultation Form

Men's Consultation Form

Personal Information

BMI Results for Adults Over 35: