Medical Questionnaire – Men Only Please complete, verify & submit the form below Personal DetailsSurname *Name *Date of Birth *ID Number *Physical Address *Postal Address *Home Telephone Number Work Telephone Number Mobile Number Email Marital Status *MarriedSingleDivorcedSeparatedNext of Kin *Relationship to Next of Kin *Contact Number of Next of Kin * Medical HistoryMedical Concerns *Medical History *Symptoms * Medication & VitaminsCurrent Treatment *Previous Treatment *Surgical History *Allergies * Further EvaluationLibido *How would you describe your libido?HealthyAverageLowMuscle Loss *Have you experienced muscle loss?YesNoErectile Dysfunction *Do you or have you experienced Erectile Dysfunction?YesNoProstatitis *Do you or have you experienced Prostatitis?YesNoWell being *What is your general sense of well being?GoodAveragePoorWeight in KG *Height in CM * General Energy LevelsMorning *GoodAveragePoorLunch *GoodAveragePoorAfternoon *GoodAveragePoorEvening *GoodAveragePoorStress Level *On a scale of 1-10 (1 being lowest and 10 being highest)12345678910Sleep Pattern *Regular & GoodVariableIrregular & Poor Please answer Yes or NoDo you suffer from Depression? *YesNoDo you suffer from Mood Swings? *YesNoDo you suffer from Anxiety? *YesNoDo you experience Aggressive Behaviour? *YesNoDo you suffer from Irritability? *YesNoDo you suffer from a lack of Motivation? *YesNo Lifestyle ChoicesAre you a Smoker? *YesNoDo you consume Alcohol? *YesNoDo you use Recreational Drugs? *YesNoDo you get Adequate Exercise? *YesNoHave you been exposed to Toxic Substances? *YesNo Date of Latest Medical ExaminationProstate Examination PSA Bone Density Sonar Gastroscopy Colonoscopy Other If other please specify Please answer as honestly as possibleGive 5 reasons why you want to LIVE *Do you believe in Our Almighty Creator? *YesNoDo you believe that your ailment can be cured? *YesNoWill you abide by our programme? *we will not change your Doctor or prescription if you so desireYesNo VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: Share on Facebook
