Men Health Information Intake Form

The Men Health Information Intake Form is a document used by healthcare providers to collect information from male patients. The form includes sections on personal information, medical history, family history, and lifestyle habits. Healthcare providers can use the information collected on the form to provide better care for their patients.

Time to complete

3 minutes

Eligibility

Male patients over the age of 18.

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Questions for Men Health Information Intake Form

1.

Name:

The answer should be a text input.
2.

Address:

The answer should be a text input.
3.

Phone Number:

The answer should be a phone number.
4.

Date of Birth:

The answer should be a date input.
5.

Social Security Number:

The answer should be a text input.
6.

Medical History:

The answer should be a text input.
7.

List any chronic illnesses or conditions you have:

The answer should be a text input.
8.

List any medications you are currently taking:

The answer should be a text input.
9.

List any allergies you have:

The answer should be a text input.
10.

List any surgeries you have had:

The answer should be a text input.
11.

List any hospitalizations you have had:

The answer should be a text input.
12.

Family History:

The answer should be a text input.
13.

List any chronic illnesses or conditions that run in your family:

The answer should be a text input.
14.

List any family members who have died prematurely:

The answer should be a text input.
15.

Do you smoke?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
16.

Do you drink alcohol?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
17.

Do you use recreational drugs?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
18.

Do you have unprotected sex?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
19.

Do you have multiple sexual partners?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
20.

Do you have a sedentary lifestyle?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
21.

Do you eat a balanced diet?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
22.

Do you eat fast food often?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
23.

Do you eat junk food often?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
24.

Do you get enough exercise?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure
25.

Do you suffer from stress?

The answer should be a single choice:
  1. Yes
  2. No
  3. Unsure

Similar Ideas

  • Medical History Form
  • Patient Health History Form
  • Family Health History Form
  • Personal Health History Form

Here are some FAQs and additional information
on
Men Health Information Intake Form

How frequently do you see a doctor or other healthcare provider?

This answer will vary depending on the individual's health and lifestyle. However, on average, men visit the doctor less often than women.

How often do you get a physical examination?

Again, this answer will vary depending on the individual's health and lifestyle. However, men are less likely than women to get a physical examination on a regular basis.

How often do you get routine screenings for things like cancer or cholesterol?

Routine screenings are important for early detection of disease. Men are less likely than women to get routine screenings for things like cancer or cholesterol.

How often do you exercise?

Exercise is important for overall health and wellness. Men are less likely than women to exercise on a regular basis.

How often do you eat a healthy diet?

A healthy diet is important for overall health and wellness. Men are less likely than women to eat a healthy diet on a regular basis.

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