Yachter Bio-Nutritional Department: Male Wellness Questionnaire

Male Wellness History Questionnaire

GENERAL INFORMATION

Name Todays Date

Age Date of Birth Height Weight Occupation

CURRENT COMPLAINTS/CONCERNS

Please list your chief symptoms in order of decreasing severity, starting with the worst one. Please note how long each symptoms has been present

Problem	Frequency	Mild	Moderate
e.g. Headaches 1	June 2007	4 times per week	Mild / moderate / severe
2
3
4
5
6
7

ALLERGIES

Medication/Supplement/Food

Reaction

IMMUNIZATION HISTORY

Have you received any vaccinations in the last 5 years? Yes No If Yes, please list.

DENTAL HISTORY

Do you currently have any amalgam, silver, metal, and/or gold fillings? Yes No

If Yes, how many?
If Yes, please list which kinds

How long have you had these fillings?

If you do not have any fillings in your mouth, have you had any fillings removed in the last 12 months?
Yes No
Have you had any dental work done in the last 12 months? Yes No

MEDICATIONS & SUPPLEMENTS

Medications: Please list any medications that you
are currently taking or have taken in the last month,
including antibiotics, non-prescription drugs, and
prescription drugs.

Supplements: List all vitamins, minerals and other nutritional supplements that you are currently taking.

Medication Name	Dosage

Supplement Name/Brand	Dosage

Have your medications or supplements ever caused you unusual side effects or problems?
Yes No If Yes, please describe

SLEEP/REST

Average number of hours you sleep > 10 8 –10 6–8 < 6

Do you have trouble falling asleep? Yes No

Do you feel rested upon awakening? Yes No

Do you have problems with insomnia? Yes No

Do you snore? Yes No

Do you use sleeping aids? Yes No
Explain

LIFESTYLE INDICATORS

TOBACCO HISTORY
Currently using tobacco?   Yes No How many years? Packs per day:
If Yes, what type? Cigarette Smokeless Cigar Pipe Patch/Gum
Previous smoking: How many years? Packs per day:

Are you exposed to 2nd hand smoke? If Yes, please explain:

ALCOHOL INTAKE
How many drinks currently per week? 1 drink = 5 ounces wine, 12 oz. beer, 1.5 ounces spirits
None 1-3 4-6 7-10 >10
Previous alcohol intake? Yes (Mild Moderate High

CAFFEINE INTAKE
How many cups of coffee per day?   None 1-3 4-6 7-10
How many cans of soda per day?   None 1-3 4-6 7-10
Is the soda you drink, diet soda?   Yes No

SYMPTOMS

SYMPTOMS	Mild	Moderate	Severe	Additional Comments
Body/joint aches
Weight gain
Weight loss
Elevated blood pressure
Elevated cholesterol
Digestive problems
Head hair loss
Dry skin/thinning skin
Constant hunger
Sweet cravings
Caffeine cravings
Salt cravings
Anger/Aggression
Irritability
Low mood/Depression
Concentration problems
Foggy thinking
Increased fatigue
Lowered Libido
Erectile Dysfunction
Frequent need to urinate
Pain with urination
Bone loss/osteoporosis
Low blood sugar
Other

MISCELLANEOUS

Have you had a vasectomy? Yes No When?

Have you had a reverse vasectomy? Yes No When?

Have you experienced symptoms related to the vasectomy? Yes No Explain

Do you have a history of prostate problems? Yes No Explain

Date of last Prostate Exam

Most recent PSA results Date

How often do you exercise? Never Rarely Sometimes Regularly

Other information for us to know: