16622 North Dale Mabry Highway - Tampa, Florida

Phone:  (813) 265-8885

Fax:  (813) 265-8898

Personal Health Profile - Men

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Name:

Please list all medical problems you currently have and those you have had in the past:

Please list any injuries, accidents, surgeries or hospitalizations you have had:

When was your last prostrate exam?

Was it normal?

 Yes No

Have you ever had an abnormal prostrate exam?

Yes

No

  

Have you ever had abnormal PSA levels?

Yes

No

Are you allergic to any medicines?

Yes

No

If yes please list medicines you are allergic to:

Please list any medicines and supplements you are taking:

Social History:

Current marital status:

Married

Single

Do you have children?

Yes

No

If so, what are their ages?

Do you smoke?

Yes

No

If so, how much and how often?

Do you drink alcohol?

Yes

No

If so, how much and how often?

Do you exercise?

Yes

No

If so, what do you do and how often?

If you work outside the home, what do you do?

Describe the level of stress you are experiencing in your life.  What do you do to help cope?

 

Briefly describe your diet on a typical day:

Please list any health problems of members of your immediate family (mother, father,
brothers, sisters and children):

From the following list of problems, please check those that pertain to you:
Hot flashes Night sweats Chest pain Foggy thinking  
Memory lapses Tearful Depressed Heart palpitations  
Bone loss Disturbed Sleep Headaches Aches and pains  
Fibromyalgia Morning fatigue Evening fatigue Stress  
Sugar Craving Decreased libido Shortness of breath Loss of scalp hair  
Acne Mood swings Nervous Irritable  
Anxiety Water retention Rapid aging Slow pulse rate  
Indigestion Hair dry or brittle Thinning skin Infertility problems  
Constipation Rapid heartbeat Hearing loss Goiter  
Hoarseness Allergies Cold body temperature    

Weight gain in the abdomen

 Sensitivity to chemicals Nails breaking or brittle
Decreased sweating Decreased muscle size Decreased stamina

Decreased facial or body hair

 Difficulty achieving or maintaining an erection
 
Swelling or puffy eyes or face Elevated Cholesterol or Triglycerides

Incontinence or rising to urinate more than once at night
 

Other (please specify):

  
 

 
 

 

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