Medical History Form MALE – Autonomic Coaching

Date

Name

First

Last

birth date

Weight

Height

Blood Pressure

Primary Health Concerns:

When did your health concerns begin?

Please use this space below to share additional information with us regarding your health concerns.

Occupation:

Please Describe Your Hobbies:

Please list current stressors in your life:

Cardiovascular Health

Pulmonary (Lung)

Circulatory

Gastrointestinal

Gynecologic

Urinary

Obesity or Weight Loss

Weight at 18?Weight at 18?

Weight gain or loss for how long?Weight gain or loss for how long?

Endocrine

Skin

Neuro-Psychiatric

Cancer (Past or Present) [very important]

Sexual

NO PROBLEMS

Decreased in or loss of libido

Decreased sexual vigor

Orgasmic Problems

Rheumatoid, Joint and Back

General Information:

Previous Prescription Medications:

Current Prescription Medications:

Anticoagulants? Since when ________

Past or Present Problems with:

Dental

Orthodontics?Orthodontics?

explainexplain

Braces?Braces?

If yes complications?If yes complications?

Amalgam fillings? How many?Amalgam fillings? How many?

Root Canals? How many?Root Canals? How many?

Previous Gum Inflammation (gingivitis)Previous Gum Inflammation (gingivitis)

Supplements Minerals, Herbs or Other

Operations or Hospitalizations Dates and reasons

When last were you ill?

Diagnosis:

Example of Typical Daily Meals

Nutritional

Do you eat Breakfast?Do you eat Breakfast?

Are you a vegetarian?

Anorexia or bulimia

Sleep, Exercise and Relaxation:

How many hours of sleep?How many hours of sleep?

Types of exerciseTypes of exercise

How often?How often?

Methods of Relaxation:Methods of Relaxation:

Dental

Orthodontics? Orthodontics?

If yes, explainIf yes, explain

Braces?Braces?

If yes complications?If yes complications?

Amalgam fillings? How many?Amalgam fillings? How many?

Root Canals? How many?Root Canals? How many?

Previous Gum Inflammation (gingivitis)Previous Gum Inflammation (gingivitis)

Social Habits

Coffee: How many cups daily?Coffee: How many cups daily?

Tea: How many cups daily?Tea: How many cups daily?

□ Smoking?□ Smoking?

Cigarettes How many?Cigarettes How many?

Cigars How many?Cigars How many?

Pipe How often?Pipe How often?

OtherOther

AlcoholAlcohol

wine Intake per week?_______wine Intake per week?_______

Beer Intake per week?Beer Intake per week?

Hard liquor Intake per week?Hard liquor Intake per week?

DrugsDrugs

Cocaine frequencyCocaine frequency

Marijuana frequencyMarijuana frequency

Psychedelics frequencyPsychedelics frequency

OtherOther

Past Exams and Evaluations:

Date of last prostate exam:Date of last prostate exam:

Abnormal findings?Abnormal findings?

Please explain:Please explain:

In the past have you had any of the following (circle):

MALE REPRODUCTIVE HISTORY & FERTILITY STATUS

Have you had a sperm count?Have you had a sperm count?

Number (million)Number (million)

% Malformed sperm?% Malformed sperm?

% Immotile sperm% Immotile sperm

Clumping?Clumping?

RECENT SCREENINGS AND EXAMS

General Information:

About Us:

Questions:

Misc.