3 minutes to complete
Male patients over the age of 18.
Name:
Address:
Phone Number:
Date of Birth:
Social Security Number:
Medical History:
List any chronic illnesses or conditions you have:
List any medications you are currently taking:
List any allergies you have:
List any surgeries you have had:
List any hospitalizations you have had:
Family History:
List any chronic illnesses or conditions that run in your family:
List any family members who have died prematurely:
Do you smoke?
Do you drink alcohol?
Do you use recreational drugs?
Do you have unprotected sex?
Do you have multiple sexual partners?
Do you have a sedentary lifestyle?
Do you eat a balanced diet?
Do you eat fast food often?
Do you eat junk food often?
Do you get enough exercise?
Do you suffer from stress?