Men’s Evaluation

Please fill out the form below to the best of your ability.

About You

About You

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Medical Information

Medical
Information

Do you have another primary care provider to add?
Do you have another primary care provider to add?

Personal Medical Information

Please indicate self or family next to each condition that applies

Prescription Information

Prescription
Information

Please list any PRESCRIPTION medications you are currently using

Please List ALL Over-The-Counter (OTC) products you currently use, both occasionally and regularly.
PLEASE INCLUDE vitamins, minerals, herbal products, pain relievers, cold medicine, sleep aids, etc...

Current Symptoms

Current
Symptoms

Move the slider for EACH SYMPTOM which best describes how you have been feeling.

0 = None (symptom not present)

1 = Mild (present but not distressing)

2 = Moderate (distressing, but not interfering with daily life)

3 = Severe (very distressing, interferes with daily life

Submit

Submit

For questions regarding what all the consultation fee includes, please contact us at 937-761-2606.

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