Male Lifestyle Questionnaire

New Patient Contact

Mailing Address

Background Information

Date of Birth

Occupational Profile

Your Household

Your BHRT Goals

Please describe your expectations and goals as a patient at RejuvinAge.

Medical History

Cancer diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Diabetes diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Heart disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Arthritis diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Liver disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

High cholesterol / triglycerides diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Endocrine / thyroid abnormalities?

Myself

Sibling

Parent

N/A

Please Select...

High blood pressure?

Myself

Sibling

Parent

N/A

Please Select...

Bowel disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Neurological disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Lung disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Kidney disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Medical History Cont'd

Stomach disease diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Blood clots?

Myself

Sibling

Parent

N/A

Please Select...

Weight control problems?

Myself

Sibling

Parent

N/A

Please Select...

Osteoporosis / Osteopenia diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Anemia diagnosis?

Myself

Sibling

Parent

N/A

Please Select...

Alcohol abuse?

Myself

Sibling

Parent

N/A

Please Select...

Drug abuse?

Myself

Sibling

Parent

N/A

Please Select...

Have you had any surgical procedures?

Yes

No

Please select...

Past serious injury or illness?

Yes

No

Please select...

Tests & Examinations

Have you had a colonoscopy?

Yes

No

Please select...

When was your last Colonoscopy?

Invalid Input

Have you had a prostate exam?

Yes

No

Please select...

When was your last prostate exam?

Invalid Input

Have you had a bone density test?

Yes

No

Please select...

When was your last bone density test?

Invalid Input

Have you had a chest x-ray?

Yes

No

Please select...

When was your last chest x-ray?

Invalid Input

Have you had an EKG?

Yes

No

Please select...

When was your last EKG?

Invalid Input

Medications & Supplements

Do you have any medication allergies?

Yes

No

Please select...

Are you currently taking any medication(s)?

Yes

No

Please select...

Are you currently taking any supplements?

Yes

No

Please explain...

Health & Lifestyle

What is your daily water consumption?

Please select...

What is your daily caffeine consumption?

Please select...

Are you a tobacco user?

Currently use

Previously used

Never used

Please select...

Do you consume alcohol?

Currently use

Previously used

Never used

Please select...

Do you take recreational drugs?

Currently use

Previously used

Never used

Please select...

Health Survey

Do you experience fatigue?

Yes

No

Please select...

Do you have any skin disorders?

Yes

No

Please select...

Do you experience visual problems?

Yes

No

Please select...

Hearing loss or ringing in ears?

Yes

No

Please select...

Do you experience allergy symptoms?

Yes

No

Please select...

Do you experience headaches?

Yes

No

Please select...

Do you have spider or varicose veins?

Yes

No

Please select...

Lumps in neck, armpits, or groin?

Yes

No

Please select...

Do you experience heart palpitations?

Yes

No

Please select...

Do you have shortness of breath?

Yes

No

Please select...

Health Survey Cont'd

Do you experience abdominal pain?

Yes

No

Please select...

Do you experience regular diarrhea?

Yes

No

Please select...

Do you experience regular constipation?

Yes

No

Please select...

Do you urinate thru at night?

Yes

No

Please select...

Do you have a sexually transmitted disease?

Yes

No

Please select...

Fluid retention in hands, legs, or ankles?

Yes

No

Please select...

Do you have abdominal bloating?

Yes

No

Please select...

Do you suffer from indigestion?

Yes

No

Please select...

Do you have acid reflux?

Yes

No

Please select...

Health Survey Cont'd

Do you have any food allergies?

Yes

No

Please select...

Do you have any food sensitivities?

Yes

No

Please select...

Do you have oily skin?

Yes

No

Please select...

Do you have a history of adult acne?

Yes

No

Please select...

Do you have excessive body hair?

Yes

No

Please select...

Do you suffer from joint pain?

Yes

No

Please select...

Do you suffer from back or spine pain?

Yes

No

Please select...

Do you have difficulty losing weight?

Yes

No

Please select...

Do you have a lack of mental alertness?

Yes

No

Please select...

Do you suffer from poor memory?

Yes

No

Please select...

Health Survey Cont'd

Do you suffer from poor concentration?

Yes

No

Please select...

Have you noticed a decrease in energy?

Yes

No

Please select...

Do you suffer from sleep problems?

Yes

No

Please select...

Do you have a decreased self-image?

Yes

No

Please select...

Do you experience rapid mood swings?

Yes

No

Please select...

Do you have dry or brittle nails?

Yes

No

Please select...

Do you have dry hair?

Yes

No

Please select...

Is your hair thinning or falling out?

Yes

No

Please select...

Do you have cold hands or feet?

Yes

No

Please select...

Male Hormone Quiz

Do you have any changes in appetite?

Yes

No

Please select...

Do you have insomnia or oversleep?

Yes

No

Please select...

Do you have a loss of energy or increased fatigue?

Yes

No

Please select...

Are you restless or irritable?

Yes

No

Please select...

Do you have feelings or worthlessness or inappropriate guilt?

Yes

No

Please select...

Do you have difficulty concentrating or making decisions?

Yes

No

Please select...

Do you have thoughts of death or suicide?

Yes

No

Please select...

Do you have a lack of energy

Yes

No

Please select...

Do you have a decrease in strength or endurance?

Yes

No

Please select...

Have you lost height?

Yes

No

Please select...

Male Hormone Quiz Cont'd

Are you of African American descent?

Yes

No

Please select...

Are you of Latino descent?

Yes

No

Please select...

Have you noticed a decreased "enjoyment of life"?

Yes

No

Please select...

Are you sad and or grumpy?

Yes

No

Please select...

Have you noticed deterioration in your activity level?

Yes

No

Please select...

Has there been deterioration in your work activity level?

Yes

No

Please select...

Are you falling asleep after dinner?

Yes

No

Please select...

Are your erections less strong?

Yes

No

Please select...

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

Yes

No

Please select...

Male Hormone Quiz Cont'd

How often have you had a sensation of not completely emptying your bladder after urinating?

Please select...

How often have you had to urinate again less than 2 hours after you have finished urinating?

Please select...

How often have you found you stopped and started again several times while urinating?

Please select...

How often have you found it difficult to postpone urination?

Please select...

How often have you experienced a weak or slow urinary stream?

Please select...

How often have you had to push or strain to begin urination?

Please select...

How many times do you most typically get up to urinate?

Please select...

Benign Prostatic Hyperplasia (BPH) diagnosis?

Yes

No

Please select...

Have you used hormone replacement?

Yes

No

Please select...

Bioidentical Hormone Replacement Therapy

Before today, how long have you been considering or researching BHRT?

Under 30 days

2-5 months

6-12 months

Over 12 months

Please select

How did you first learn about RejuvinAge?

Payment Information

Cardholder Name

Cardholder Email Address

Card Number

Card Expiration

Invalid Input

Security Code

Charge Amount

$0.00

Terms of Enrollment

Prior to processing payment, please review the following terms:

Pre-paid consultations are non-refundable but may be rescheduled.
By proceeding, your credit or debit card will be charged.

I understand program appointments require in-person visits to our Virginia Beach clinic however initial consultations may be conducted remotely upon request.

I agree to RejuvinAge's patient appointment and refund policies.

You must agree to terms to proceed.

Male Questionnaire

New Patient Contact

Mailing Address

Background Information

Your Household

Your BHRT Goals

Medical History

Medical History Cont'd

Tests & Examinations

Medications & Supplements

Health & Lifestyle

Health Survey

Health Survey Cont'd

Health Survey Cont'd

Health Survey Cont'd

Male Hormone Quiz

Male Hormone Quiz Cont'd

Male Hormone Quiz Cont'd

Bioidentical Hormone Replacement Therapy

Payment Information

Terms of Enrollment

For Women

For Men

BHRT Resources

Privacy & Use

Male Questionnaire

New Patient Contact

Mailing Address

Background Information

Your Household

Your BHRT Goals

Medical History

Medical History Cont'd

Tests & Examinations

Medications & Supplements

Health & Lifestyle

Health Survey

Health Survey Cont'd

Health Survey Cont'd

Health Survey Cont'd

Male Hormone Quiz

Male Hormone Quiz Cont'd

Male Hormone Quiz Cont'd

Bioidentical Hormone Replacement Therapy

Payment Information

Terms of Enrollment

For Women

For Men

BHRT Resources

Privacy & Use

Keep Connected