Men'sHealth HistoryPlease enable JavaScript in your browser to complete this form.Today's DateName *FirstLastSexChoice 4MaleBirthdayMM/DD/YYYYPhoneXXX-XXX-XXXXEmail *AgeHeightFeet' and Inches"Weight (lbs)poundsHas Your Weight Changed in the Past Year?Choice 3YESNOIf YES, How Much?poundsBlood Pressure (without medication)Systolic/DiastolicResting PulseBPM (beats per minute)Exposed to pesticides or heavy metals (in food, water, and/or the air)?YESNOIf YES, can you provide test results?YESNOIncreased fat on chest or lost hair on arms, legs, and chest?YESNOOften tired or have low energy?YESNODecreased muscle mass?YESNOIncreased abdominal fat?YESNOBone loss or bone fractures?YESNODiagnosed with Low-T (low testosterone)?YESNOIf YES, can you provide test results?YESNOLost or low vitality and sex drive?YESNOTroubles concerning erection or ejaculation?YESNOHas the quality of your orgasm, or force of release, diminished?YESNOProstatitis ( inflammation of the prostate)?YESNOIf YES, can you provide test results?YESNOEnlarged Prostate?YESNOLumps in groin area or just above and to the side of the penis?YESNODiagnosed with prostate cancer?YESNOIf YES, can you provide test results?YESNOPlease use this space to write in any other important health consideration you may have specific to gender. Please be as specific as possible. *Submit