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Broken Arrow (opt. 1), Tulsa (opt. 2)

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811 W. New Orleans St., #101
Broken Arrow, OK 74011

4132 E. 51st St. | Tulsa, OK 74135

811 W. New Orleans St., #101 • Broken Arrow, OK 74011

4132 E. 51st St. | Tulsa, OK 74135

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Male Hormone Consultation Form

After completing this Male Hormone Consultation Form, our pharmacy team will reach you via phone to confirm what date your phone consultation will take place. We look forward to helping you!

"*" indicates required fields

Date*

MM slash DD slash YYYY

Personal Information

Name*

First Last

Are you a vitality program member?*

Yes

No

Date of Birth*

MM slash DD slash YYYY

Age*

Phone*

Work Phone

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Height*

Weight*

BMI Results for Adults Over 35:
19-26.9 Recommended
27-29.9 Overweight
30-39.9 Obese
40 (+) Morbidly Obese

Waist Circumference*

Waist: Hip Ratio (waist/hip)*

Medical Status:

Primary Physician*

Primary Physician Phone*

Secondary Physician

Secondary Physician Phone

General Health*

Excellent

Good

Fair

Poor

Medical & Social History: Please check the following that apply to you.*

High Blood Pressure

Cardiovascular Disease

Osteoporosis

Tobacco Use

Alcohol Use

Insomnia

Depression

High Cholesterol

Diabetes Mellitus

Benign Prostatic Hyperplasia

Asthma/COPD

Erectile Dysfunction

Malnutrition

Cancer

Other

If you checked Cancer, please explain.

If you checked Other, please explain.

Names of ALL prescription medications, taken in last 6 months. Include strength and how you take them:

Indicate any herbal products you have taken: (Evening Primrose Oil (EPO), Chaste Tree Berry, Dong Quai, Black Cohosh Ginseng, Melatonin, etc): Other:

Names of ALL Vitamins, Supplements, Non-prescription medicines, or other OTC products that you are currently using:

Drug Allergies

Family History: List Important Diseases

Mother

Mother Living / Deceased

Living

Deceased

Father

Father Living / Deceased

Living

Deceased

Brothers

Brothers Living / Deceased

Living

Deceased

Sisters

Sisters Living / Deceased

Living

Deceased

Aunts

Aunts Living / Deceased

Living

Deceased

Uncles

Uncles Living / Deceased

Living

Deceased

Paternal Grandma

Paternal Grandma Living / Deceased

Living

Deceased

Paternal Grandpa

Paternal Grandpa Living / Deceased

Living

Deceased

Maternal Grandma

Maternal Grandma Living / Deceased

Living

Deceased

Maternal Grandpa

Maternal Grandpa Living / Deceased

Living

Deceased

Do you feel more fatigued and/or tired than usual?*

N/A

Mild

Moderate

Severe

Have you noticed a decrease in your muscle mass?*

N/A

Mild

Moderate

Severe

Have you experienced a loss in muscle strength?*

N/A

Mild

Moderate

Severe

Have you experienced an increase in joint and/or muscle pains?*

N/A

Mild

Moderate

Severe

Have you noticed an increase in your waist size?*

N/A

Mild

Moderate

Severe

Do you have trouble losing weight?*

N/A

Mild

Moderate

Severe

Have you experienced a loss in height?*

N/A

Mild

Moderate

Severe

Do you have a decrease in your sex drive?*

N/A

Mild

Moderate

Severe

Have you experienced difficulty in establishing and/or maintaining full erections?*

N/A

Mild

Moderate

Severe

Have you experienced changes in your usual sleep pattern?*

N/A

Mild

Moderate

Severe

Do you feel a decrease in your mental sharpness?*

N/A

Mild

Moderate

Severe

Have you had trouble concentrating?*

N/A

Mild

Moderate

Severe

Do you experience less enjoyment in personal interests and hobbies?*

N/A

Mild

Moderate

Severe

I am ________ years old*

I feel ________ years old*

Please select 3 times that work best for a phone consultation with one of our pharmacists. Our times offered are Monday - Friday with time blocks from 9:00am-12:00pm, 12:00pm-3:00pm or 3:00pm-6:00pm. Consults typically last between 30 minutes and one hour. We will check availability and get back with you with a specific time.

Date*

MM slash DD slash YYYY

Time Block*

Date*

MM slash DD slash YYYY

Time Block*

Date*

MM slash DD slash YYYY

Time Block*

Name

This field is for validation purposes and should be left unchanged.

40777

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