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Male Patient Information

First Name*
Last Name*
Address*
City*
State*
Zip Code*
Age*  
Email*
Phone*
   
Sexual History
1. Age of first sexual contact:
2. Are you sexually active? yes no
3. Do you have a history of Sexually Transmitted Diseases? yes no
If yes, please list:
4. Have you had a sperm count? yes no
Results:
5. Have you had the Mumps? yes no
Date:
6. Have you had Testicular Cancer? yes no
Date:
7. Do you have Prostate Problems? yes no
If yes, please describe:
8. Have you had blood in your urine? yes no
If yes, when & treatment:
9. Have you had any bladder or kidney problems?
yes no
If yes, when & treatment:
10. Do you have erectile dysfunction? yes no
If yes, please describe:
11. Do you have:
Fatigue
Decrease of memory
Decrease of energy level
Decrease of sexual drive
12. Do you suffer from:
Anxiety
Irritability
Mood swings
Migraines
13. How have you dealt with these symptoms?
14. Do you initiate intercourse? yes no
15. Is intercourse satisfying? yes no
16. Do you achieve orgasm? yes no
17. Do you suffer from premature ejaculation?
yes no
18. How often do you have intercourse?
19. Is your sex drive the same as it was five
years ago? yes no
Describe:
20. List any other sexual dysfunctions:
21. Have you experienced weight gain in the last one-two years? yes no
If yes, please describe:
22. Have you lost greater than 10 pounds in less than a month? yes no
If yes, why?
23. Are you HIV positive? yes no
If yes, when? Describe:
24. Have you ever been tested for AIDS?
yes no
Results?
25. Have you fathered any children? yes no
If yes, how many?
26. Have you had your Testosterone level taken?
yes no
27. List current medications:
28. Sexual Orientation?
Heterosexual
Homosexual
Bisexual
   
Past Medical History
1. Do you have diabetes? yes no
2. Do you have/had hypertension? yes no
3. Do you have heart disease? yes no
4. Do you have a heart murmur? yes no
5. Do you have/had kidney disease? yes no
6. Have you ever been treated for psychiatric problems? yes no
7. Have you ever had rheumatic fever?
yes no
8.
 Do you have mitral valve prolapse? yes no
9.
 Have you ever had a urinary tract infection?
yes no
10.
 Have you ever had hepatitis/liver disease?
yes no
11. Have you ever had varicosities/phlebitis?
yes no
12. Do you have any thyroid problems?
yes no
13. Have you had any major accidents?
yes no
14. Have you ever had any blood transfusions?
yes no
15. Do you have asthma/lung disease?
yes no
16. Do you have lupus?
yes no
17. Do you have arthritis?
yes no
18.

Do you have any Drug Allergies? yes no
If yes, please list:
19. Please list all surgeries:
20.

Please list any other operations/hospitalizations (include year & reason):
21. Have you had any anesthesia complications?
yes no
If yes, please list:
22. Have you ever been anemic? yes no
23. Do you have an Internist or Family doctor?
yes no
Please list name, phone number:
24. Are you currently on any medications?
yes no
If yes, please list with dosage:
25. Have you had your cholesterol checked?
yes no
If yes, date last checked:
Was it normal? yes no
   
Social History
1.
 Do you smoke cigarettes? yes no
If yes, # per day? for years
2.
 Do you use street drugs? yes no
3. Do you drink alcohol? yes no
If yes, how much per day?
 
 

 

Stacey M. Johnson, M.D.

Physicians' Medical Center of the Ozarks · 17 Medical Plaza · Mountain Home, AR 72653
Toll-Free 1-866-749-7633 · (870) 425-6212 · Fax (870) 424-3774 · www.physmedcenter.com

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09/25/2006 SJMD 301
Services About Physician's Medical Center Physicians and Staff Patient Care News and Events Resources Facility Patient Testimonials Patient Education View Videos Online Patient Education Contact Us Home Location / Maps Site Map View Videos Online MD Articles and Publications