Male Health and Lifestyle Questionnaire
Name(*)

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Email(*)

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Date(*)

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Age(*)

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Address(*)

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City, State, Zip(*)

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Home Phone #(*)

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Work Phone #(*)

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Cell Phone #(*)

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Fax #

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Date of Birth(*)

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Goals(*)

Invalid Input What are your expectations as a patient at RejuvinAge?

Medical and family history. Please check the appropriate answer or leave blank if not relevant.

Invalid Input Initial Comments (if required)
1. Cancer

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2. Diabetes

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3. Heart Disease

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4. Arthritis

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5. Liver Disease

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6. Elevated Cholesterol / Triglycerides

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7. Endocrine / Thyroid Abnormalities

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8. High Blood Pressure

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9. Bowel Disease

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10. Neurological Disease

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11. Lung Disease

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12. Kidney Disease

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13. Stomach Disease

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14. Blood Clots

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15. Weight Control Problems

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16. Osteroporosis / Osteopenia

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17. Anemia

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18. Alcohol

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19. Drug Abuse / Recreational

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Please explain any checked box.

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20. Surgical Procedures

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21. Serious Injuries, Accidents, or Serious Illness?

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22. Allergies to Medications or Drugs?

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23. Medications: Including Over the Counter and Hormones

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Medication # 1

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Medication # 2

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Medication # 3

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Medication # 4

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Medication # 5

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24. Supplements

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Supplement #1

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Supplement #2

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Supplement #3

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Supplement #4

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Supplement #5

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25. Marital Status(*)

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26. Number of Children(*)

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Number of People in Your Household(*)

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27. Occupation(*)

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28. Tobacco Use(*)

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If You Checked "Yes" to Smoking, Please Explain

Invalid Input Example 1: Currently smoke 2 packs/day for 10 years. Example 2: Previously smoked 2 packs/day for 10 years.
29. Alcohol Consumption: # of drinks per week.(*)

Invalid Input If you do not consume alcohol, please list "0".
30. Caffeine / Coffee / Tea / Soda: # per day:(*)

Invalid Input If you consume none of these, please input "0".
31. Water: Daily consumption (*)

Invalid Input Example: "8 glasses"

32. Fatigue(*)

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33. Skin Disorders(*)

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34. Visual Problems(*)

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35. Hearing loss / ringing in ears(*)

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36. Allergy Symptoms(*)

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37. Headaches(*)

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38. Spider or varicose veins(*)

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39. Lumps in neck, armpits, groin(*)

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41. Shortness of breath at rest(*)

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42. Shortness of breath with exertion(*)

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43. Palpitations(*)

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44. Abdominal Pain(*)

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45. Diarrhea(*)

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46. Constipation(*)

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47. Blood in stool(*)

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48. Black Stool(*)

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49. Difficulty Urinating(*)

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50. Leaking urine(*)

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51. Urinating at night(*)

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52. Sexually transmitted disease(*)

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53. Muscle, bone, or joint pain(*)

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Please explain any answer checked "Yes".

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54. Fluid retention in hands, legs, ankles(*)

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55. Abdominal Bloating(*)

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56. Indigestion(*)

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57. Reflux(*)

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58. Allergies(*)

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59. Food sensitivities(*)

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60. Please list food allergies

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61. Oily skin(*)

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62. History of acne(*)

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63. Excessive body hair(*)

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64. Boils or sty's (*)

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65. Joint Pain(*)

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66. Carpal tunnel / wrist / hand pain(*)

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67. Back or Spine problems(*)

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68. Difficulty in losing wieght(*)

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69. Lack of mental alertnes(*)

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70. Decreased self image(*)

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71. Memory Problems(*)

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72. Energy loss(*)

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73. Sleep Problems(*)

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Describe sleep problems (If applicable)

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74. Poor Concentration(*)

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75. Rapid mood swings(*)

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76. Dry hair(*)

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77. Brittle nails(*)

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78. Cold hands or cold feet(*)

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79. Hair thinning or falling out(*)

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80. Date of last Colonoscopy

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Date of last Bone Density

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Date of last Chest X Ray

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Date of last Rectal Exam

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Date of last EKG

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Comments (if applicable)

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1. Do you have any changes in appetite? (*)

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2. Do you have insomnia or oversleep?(*)

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3. Do you have a loss of energy or increased fatigue?(*)

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4. Are you restless or irritable?(*)

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5. Do you have feelings or worthlessness or inappropriate guilt?(*)

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6. Do you have difficulty thinking, concentrating, or making decisions?(*)

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7. Do you have thoughts of death or suicide?(*)

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8. Do you have a lack of energy(*)

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9. Do you have a decrease in strength or endurance?(*)

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10. Have you lost height?(*)

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11. Have you noticed a decreased "enjoyment of life"? (*)

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12. Are you sad and or grumpy?(*)

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13. Have you noticed deterioration in your activity level? (*)

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14. Are you falling asleep after dinner?(*)

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15. Has there been deterioration in your work activity level?(*)

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

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17. Are your erections less strong?(*)

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18. Are you over the age of 50?(*)

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19. Do you have a family history of prostate cancer?(*)

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20. Are you of African American Descent?(*)

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21. Do you have constant hip or back pain?(*)

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22. Do you have difficulty urinating?(*)

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23. Do you have painful or burning urination?(*)

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24. Do you have blood in your urine?(*)

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25. Date of last prostate exam?(*)

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Heart Disease (comments)

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26. Are you over the age of 51?(*)

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27. Has an immediate family member had any of the following?(*)

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28. Do you smoke?(*)

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29. Is your blood pressure consistently more than 135/85?(*)

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30. Is your cholesterol level more than 200?(*)

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31. Does your diet include high fat foods?(*)

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32. Do you exercise less than 1-2 times per week?(*)

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33. Do you have diabetes?(*)

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34. Are you 20 or more pounds overweight?(*)

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35. Do you have a high stress level?(*)

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36. Are you African American or Hispanic descent?(*)

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Benign Prostatic Hyperplasia (BPH) Enter comments below

Invalid Input Select the answer that best represents your response. "0" Not at all "1" = Less than 1 time in 5 "3" = About half the time "4" = More than half the time "5" = Almost always Include any initial comments below.
37. How often have you had a sensation of not completely emptying your bladder after urinating?(*)

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38. How often have you had to urinate again less than 2 hours after you have finished urinating?(*)

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39. How often have you found you stopped and started again several times while urinating?(*)

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40. How often have you found it difficult to postpone urination?(*)

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41. How often have you had a weak urinary stream?(*)

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42. How often have you had to push or strain to begin urination?(*)

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43. How many times do you most typically get up to urinate?(*)

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