New Patient Forms (Males)

New Patient Demographic Form

Please fill out the required information below. if you have any questions please feel free to call the office at (856) 751-2100.

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Height(Required)

Weight(Required)

Race(Required)

Home Address(Required)

Please input your Street Address

City(Required)

State(Required)

Zip Code(Required)

Home Phone

Cell Phone(Required)

Work

Email(Required)

How did you hear about us?

If it's a patients name, please list it below. If other - please write below

In Case of Emergency Contact:(Required)

Relationship(Required)

Cell Phone(Required)

Home Phone

Work

Preferred Pharmacy(Required)

Please input the name of your Preferred Pharmacy to receive medications

City(Required)

State(Required)

Zip Code(Required)

Pharmacy Phone Number(Required)

Symptom Checklist

Select EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE.

1. Decline in your feeling of general well-being(Required)

(general state of health, subjective feeling)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

2. Joint pain and muscular ache(Required)

(lower back pain, joint pain, pain in a limb, general back ache)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

3. Excessive sweating(Required)

(unexpected/sudden episodes of sweating, hot flushes independent of strain)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

4. Sleep problems(Required)

(difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

5. Increased need for sleep, often feeling tired(Required)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

6. Irritability(Required)

(feeling aggressive, easily upset about little things, moody)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

7. Nervousness(Required)

(inner tension, restlessness, feeling fidgety)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

8. Anxiety(Required)

(feeling panicky)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

9. Physical exhaustion / lacking vitality(Required)

(general decrease in performance, reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, of having to force oneself to undertake activities)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

10. Decrease in muscular strength(Required)

(feeling of weakness)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

11. Depressive mood(Required)

(feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

12. Feeling that you have passed your peak(Required)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

13. Feeling burnt out, having hit rock-bottom(Required)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

14. Decrease in beard growth(Required)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

15. Decrease in ability/frequency to perform sexually(Required)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

16. Decrease in the number of morning erections(Required)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

17. Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)(Required)

1. None

2. Mild

3. Moderate

4. Severe

5. Extremely Severe

Please share any additional comments about your symptoms you would like to address

Do you have cold hands and feet?(Required)

Yes

Do you have daily bowel movements?(Required)

Yes

Do you have gas, bloating, or abdominal pain after eating?(Required)

Yes

Please select your WEEKLY Activity Level based on this criteria(Required)

Physical activity that accelerates heart rate / Breathlessness

0-1 day per week (Low)

2-3 days per week (Average)

More than 3 days per week (High)

Please list any prior hormone therapy?(Required)

If None - Write NONE

Recent PSA(Required)

If None - Write NONE

Recent Digital Rectal Exam (Date):

MM slash DD slash YYYY

Recent Rectal Exam(Required)

Normal

Abnormal

Does Not Apply

History of Prostate problems or Biopsy. If so, please provide details

The ADAM (Androgen Deficiency in the Aging Male)

Please answer Yes or No to the following questions

Do you have a decrease in libido (sex drive)?(Required)

Yes

Do you have lack of energy?(Required)

Yes

Do you have a decrease in strength and endurance?(Required)

Yes

Have you lost height?(Required)

Yes

Have you noticed a decreased "enjoyment of life?"(Required)

Yes

Are you sad and/or grumpy?(Required)

Yes

Are your erections less strong?(Required)

Yes

Have you noticed a recent deterioration in your ability to play sports?(Required)

Yes

Are you falling asleep after dinner?(Required)

Yes

Has there been a recent deterioration in your work performance?(Required)

Yes

Any known drug allergies:(Required)

Yes

If Yes, please explain(Required)

Current Medications and dosage(Required)

If None - Write NONE

Nutritional/Vitamin Supplements:(Required)

If None - Write NONE

Current or Past Hormone Replacement Therapy:(Required)

If None - Write NONE

Surgeries, list all and Year:(Required)

If None - Write NONE

MEDICAL HISTORY

Please check any of the below if you have had or have

High Blood Pressure(Required)

Yes

Heart Bypass(Required)

Yes

High Cholesterol(Required)

Yes

Hypertension(Required)

Yes

Heart Disease(Required)

Yes

Stroke(Required)

Yes

Heart Attack(Required)

Yes

Blood Clot(Required)

Yes

Pulmonary Embolism(Required)

Yes

Arrhythmia(Required)

Yes

Hepatitis(Required)

Yes

HIV(Required)

Yes

Lupus(Required)

Yes

Auto-Immune DIsease(Required)

Yes

Fibromylagia(Required)

Yes

Trouble Passing Urine OR Take Flomax or Avodart(Required)

Yes

Diabetes(Required)

Yes

Chronic Liver Disease(Required)

Yes

Thyroid Disease(Required)

Yes

Arthritis(Required)

Yes

Depression/Anxiety(Required)

Yes

Psychiatric Disorder(Required)

Yes

Cancer Of Any Type(Required)

Yes

Cancer Type - Please Write Below(Required)

Do You Smoke?(Required)

Yes

If you answered Yes to the question above, please specify how many cigarettes you smoke per day.

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New Patient (FULL FORMS) - Males

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The ADAM (Androgen Deficiency in the Aging Male)

MEDICAL HISTORY

Hours of Operation

Contact

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