Name *

First Name Last Name

Phone Number *

Please enter a valid phone number.

Email *

[email protected]

Date of birth *

Date

Address *

Street Address

Street Address Line 2

City State

Zip Code

Thank you for completing the questionnaire. Your answers will help us better prepare for your visit. We sincerely want to help you achieve your wellness goals.

When was the last time you functioned well?

Did something trigger your change in health?

How does your condition affect you?

What do you think is happening and why?

ALLERGY

Drug Allergy *

Yes No

List of drug allergies

Food Allergy *

Yes No

List of food allergies

Environmental Allergy *

Yes No

List of environmental allergies

Medications

Please List the prescription and over the counter medications you take daily. (Please type N/A if you do not take any medications.) *

Supplements

Please List the nutritional supplements you take daily. (Please type N/A if you do not take any medications.) *

Over the past 6 months:

How do you rate your confidence that you could keep an erection?

5-Very High 4-High 3-Moderate 2-Low 1-Very Low

When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?

5-Almost Always or Always 4-Most Times (much more than half the time) 3-Sometimes (about half the time) 2-A few Times (much less than half the time) 1-Almost Never or Never

During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner

5-Almost Always or Always 4-Most Times (much more than half the time) 3-Sometimes (about half the time) 2-A few Times (much less than half the time) 1-Almost Never or Never

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse

5-Not Difficult 4-Slightly Difficult 3-Difficult 2-Very Difficult 1-Extremely Difficult

When you attempted sexual intercourse, how often was it satisfactory for you?

5-Almost Always or Always 4-Most Times (much more than half the time) 3-Sometimes (about half the time) 2-A few Times (much less than half the time) 1-Almost Never or Never

Do you have a decrease in libido - sex drive?

Yes No

Do you have a lack of energy?

Yes No

Do you have a decrease in strength and/or endurance?

Yes No

Have you lost weight?

Yes No

Have you noticed a decreased "enjoyment of life?"

Yes No

Are you sad and/or grumpy?

Yes No

Have you noticed a recent deterioration in your ability to play sports?

Yes No

Are you falling asleep after dinner?

Yes No

Has there been a recent deterioration in your work performance?

Yes No

Urinary Leakage

Yes No

Difficulty Urinating

Yes No

Enlarged Prostate

Yes No

Prostatitis

Yes No

Prostate Cancer

Yes No

Sexual performance

Yes No

Premature ejaculation

Yes No

Delayed ejaculation

Yes No

Ejaculatory pain

Yes No

Retrograde ejaculation

Yes No

Curvature of your penis

Yes No

Painful erections

Yes No

Decreased penile sensitivity

Yes No

Venous Leakage

Yes No

Lack of sexual satisfaction

Yes No

General Sexual Wellness

Yes No

Testosterone Hormone Replacement

Yes No

Have you had any of the following:

Penile Implant

Yes No

Erection lasting longer than 4 hours

Yes No

Herniated Lumbar Disk (lower back)

Yes No

Low Back Pain

Yes No

Low Testosterone

Yes No

Prostate surgery

Yes No

Bladder surgery

Yes No

Rectal surgery

Yes No

Enlarged Prostate (BPH)

Yes No

Prostatitis

Yes No

Elevated PSA

Yes No

What have you tried in the past to fix your problem?

Medications such as - Viagra | Cialis | Levitra

Yes No

Penile injections

Yes No

Penile pump

Yes No

Penile enhancement

Yes No

Testosterone Therapy

Yes No

Steroids

Yes No

Stem cell treatment

Yes No

Platelet Rich Plasma treatment (PRP)

Yes No

Medication(s) to help with urinary discomfort, difficulty or frequency?

Yes No

During the last month or so, how often have you had sensation of not emptying your bladder completely after you finished urinating?

0-Never or almost never have the symptom 1-Occasionally have it, less than 1 time in 5 2-Occasionally have it, less than half the time 3-Frequently have it, about half the time 4-Frequently have it, more than half the time 5-Frequently have it, almost always

During the last month or so, how often have you found it difficult to postpone urination?

0-Never or almost never have the symptom 1-Occasionally have it, less than 1 time in 5 2-Occasionally have it, less than half the time 3-Frequently have it, about half the time 4-Frequently have it, more than half the time 5-Frequently have it, almost always

During the last month or so, how often have you had a weak urinary stream?

0-Never or almost never have the symptom 1-Occasionally have it, less than 1 time in 5 2-Occasionally have it, less than half the time 3-Frequently have it, about half the time 4-Frequently have it, more than half the time 5-Frequently have it, almost always

During the last month or so, how often have you had to push or strain to begin urination?

0-Never or almost never have the symptom 1-Occasionally have it, less than 1 time in 5 2-Occasionally have it, less than half the time 3-Frequently have it, about half the time 4-Frequently have it, more than half the time 5-Frequently have it, almost always

During the last month or so, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

0-Never or almost never have the symptom 1-Occasionally have it, less than 1 time in 5 2-Occasionally have it, less than half the time 3-Frequently have it, about half the time 4-Frequently have it, more than half the time 5-Frequently have it, almost always

SLEEP

How many hours of sleep do you get each night on average?

Do you have difficulty falling asleep?

Yes No

Do you have difficulty staying asleep?

Yes No

Do you snore? Yes No Do you have difficulty with insomnia?

Yes No

Do you feel rested upon awakening?

Yes No

Do you use sleeping aids?

Yes No

EXERCISE

CARDIO/AEROBIC: Please list type of exercise, # of times per week, and time/duration (minutes)

STRENGTH/RESISTANCE: Please list type of exercise, # of times per week, and time/duration (minutes).

FLEXIBILITY/STRETCHING: Please list type of exercise, # of times per week, and time/duration (minutes).

SPORTS/LEISURE (e.g., golf): Please list type of exercise, # of times per week, and time/duration (minutes).

Do you feel motivated to exercise?

Yes No

Are there any problems that limit exercise?

Yes No

If yes, explain:

Are there any problems that limit exercise: Yes

Do you feel unusually sore or fatigued after exercise?

Yes No

If yes, explain:

Do you feel unusually sore or fatigued after exercise: Yes

Do you currently follow any of the following special diets or nutritional programs? (check all that apply)

Do you have sensitivities to certain foods?

Yes No

If yes, list food and symptoms:

Do you adversely react to: (check all that apply)

Are there any foods that you crave or binge on?

Yes No

If yes, what food?

Does skipping a meal greatly affect you?

Yes No

How many meals do you eat out per week?

0-1 2-3 4-5 >5

ON A TYPICAL DAY, WHAT DO YOU EAT?

Breakfast:

Lunch:

Snack:

Fluids:

How many servings do you eat in a typical week of these foods:

Fruits (not juice)

Legumes (beans, peas, etc)

Dairy/Alternatives

Cans of soda (regular or diet)

Vegetables (not including white potatoes)

Red meat

Fish

Nuts and Seeds

Fats and Oils

Sweets (candy, cookies, cake, ice cream, etc)

Caffeine

Do you drink caffeinated beverages?

Yes No

Coffee (cups per day)

0-1 2-3 >4

Tea (cups per day)

0-1 2-3 >4

Soda (cans per day)

0-1 2-3 >4

When you drink caffeine do you feel:

Irritable Wired Aches / Pains No adverse feelings or reactions

Smoking

Do you smoke currently?

Yes No

If yes, packs per day and number of years:

Have you attempted to quit?

Yes No

If yes, using what method:

Did you smoke previously?

Yes No

If yes, packs per day and number of years:

Alcohol

How many drinks do you drink in a week? (1 drink = 5oz wine, 12oz beer, 1.5oz spirit)

1-3 4-6 7-10 >10

Have you ever had a problem with alcohol?

Yes No

Have you ever thought about getting help to control or stop your drinking?

Yes No

Are you currently using any recreational drugs?

Yes No

STRESS

Do you feel you have an excessive amount of stress in your life?

Yes No

Do you feel you can easily handle the stress in your life?

Yes No

RELATIONSHIPS

Marital status:

Single Married Divorced Gay/Lesbian Long-Term Partner Widow / Widower

With whom do you live? (include children, parents, relatives, friends, pets)

OCCUPATION

Current occupation:

Previous occupation:

SUPPORT

Do you have resources for emotional support?

Yes No

Do you have a religious or spiritual practice?

Yes No

DENTAL

Check if you have any of the following:

Silver mercury fillings Gold fillings Root canals Implants Caps/Crowns Tooth pain Bleeding gums Gingivitis Problems with chewing

Do you brush your teeth regularly?

Yes No

Do you floss your teeth regularly?

Yes No

Have you had any mercury fillings removed?

Yes No

If yes, when:

How many fillings did you have as a kid?

If other dental concerns, explain:

ENVIRONMENTAL TOXICITY EXPOSURE

Do any of these significantly affect you?

Cigarette or Cigar smoke Perfume/colognes Auto exhaust fumes

What In your work or home environment are you regularly exposed to: (check all that apply)

Have you had a significant exposure to any harmful chemicals?

Yes No

MEDICAL HISTORY (Check all that you have now or have had in the past)

GASTROINTESTINAL

Irritable bowel syndrome GERD (acid reflux) Crohn's disease/Ulcerative colitis Peptic ulcer disease Celiac disease Gallstones Hepatitis Fatty Liver Liver Disease

RESPIRATORY

Bronchitis Asthma Emphysema Pneumonia Sinusitis Sleep apnea

URINARY/GENITAL

BPH Frequent urinary tract infections Gout Kidney stones Kidney Disease Sexually transmitted disease

ENDOCRINE/METABOLIC

Diabetes Hypothyroidism (low thyroid) Hyperthyroidism (overactive thyroid) Infertility Metabolic syndrome/Insulin resistance Eating disorder Hypoglycemia

IMMUNE SYSTEM

Diabetes Hypothyroidism (low thyroid) Hyperthyroidism (overactive thyroid) Infertility Metabolic syndrome/Insulin resistance Eating disorder Hypoglycemia

MUSCULOSKELETAL

Osteoarthritis Chronic pain Scoliosis Poor posture

SKIN

Eczema Psoriasis Acne Skin cancer

CARDIOVASCULAR

NEUROLOGICAL

Epilepsy/Seizures ADD/ADHD Headaches Migraines Autism Multiple sclerosis Parkinson's disease Dementia

MOOD

Depression Anxiety

CANCER

Lung Breast Colon Prostate Skin Other

PAST SURGICAL HISTORY (check all that apply)

Appendectomy Dental Gallbladder Heart surgery Hernia Joint replacement Prostate Tonsillectomy Vasectomy

DIAGNOSTIC TESTING (list year and if normal or abnormal)

Cardiac stress test

CIMT

Carotid Ultrasound

Colonoscopy

Coronary calcium score

CT scan

Echocardiogram

EKG

MRI

Penile Doppler and Ultrasound

Thermography

Upper endoscopy/Gastroscopy

X-ray

HOSPITALIZATION

Have you been hospitalized in the past?

Yes No

If yes, what year and why:

MUSCULOSKELETAL PAIN

Do you have musculoskeletal pain or discomfort?

Yes No

Rate your pain on a scale of 1-10, 10 being the worst pain

Describe type of pain:

Aching Dull Radiating Sharp Stabbing Throbbing

Frequency of pain

Always Occasional Almost never

Does your pain interfere with your daily activities?

Yes No

What aggravates your pain?

What relieves your pain?

Have you had professional treatment for your pain?

Yes No

If yes, explain

REGULAR USE OF MEDICATIONS (present or past)

NSAIDs (Advil, Aleve, Motrin, ibuprofen) Acid-blocking drugs/Proton pump inhibitors (Zantac, Prilosec, Nexium, etc.) Tylenol (acetaminophen)

ANTIBIOTIC USE

Childhood (before 18 years old) less than 5 times Childhood (before 18 years old) more than 5 times Adulthood (after 18 years old) less than 5 times Adulthood (after 18 years old) more than 5 times

What was the reason(s) for taking antibiotics?

STEROID USE (prednisone or other)

Childhood (before 18 years old) less than 5 times Childhood (before 18 years old) more than 5 times Adulthood (after 18 years old) less than 5 times Adulthood (after 18 years old) more than 5 times

What was the reason(s) for taking steroids?

Significantly modify your diet