Male Health History

Restoration Health Care

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Male Health History

Male Health History Form

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Please fill out and submit this male health history form prior to your initial appointment at Restoration Health Care. Feel free to call us in Hot Springs or Bentonville if you have any questions.

1) Patient’s legal name:*

2) Date of birth:*

3) Street address:*

4) City:*

5) Zip:*

6) Phone number:*

7) Email:*

8) Drug allergies:*

9) Name of insurance:*

10) Policy holder's name:*

11) Insurance policy number:*

12) Current weight:*

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Use the following scale for questions 13-19: a rating of 1-4, 1 being mild through 4 being severe

13) Rate: Lack of energy or feelings of fatigue:*

14) Rate: Feelings of depression:*

15) Rate: Erection or potency problems:*

16) Rate: Loss of motivation:*

17) Rate: Decrease in libido:*

18) Rate: Decrease in physical stamina:*

19) Rate: Increased irritability or bad temper:*

20) History of cancer, if so, what kind?*

Yes

List cancer:*

21) History of high blood pressure?*

22) History of diabetes?*

Yes

23) List current problem or concerns:*

24) Any surgeries, if so, what kind?*

Yes

List surgeries:*

25) List current medication:*

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Restoration Health Care

With locations in Hot Springs and Bentonville, AR, Restoration Health Care specializes in health and wellness services. Virtual appointments available. Same-day appointments. Walk-in appointments. Contact us today.

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