Contact Now - Sugar Land/Houston & Katy

Click here to Contact Now - Mumbai

Are you having any of these symptoms?
Anxiety
Chronic Fatigue
Decreased Memory
Depression
Fibromyalgia
Foggy Thinking
Irritability
Lack of Concentration
Lethargy
Loss of Libido
Low Energy
Mood Swings
Muscle Weakness
Pigmentation 
Poor Sleep 
Tired Look 
Weight Gain 
Wrinkled Skin

Is it early aging or Hormone imbalance ?

Find out now: Visit our clinics in Katy Sugar Land, Houston, Texas, to learn more about Natural Bioidentical Hormone Replacement Therapy
Call now: 713-772-7887

Male Questionnaires ::

Please complete the following form and an Amaya Client Coordinator will be glad to contact you.
 * Required fields.
   
Name: *
Gender: Male
DOB:
Age:
Physical Address:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
Email: *
Cell Number: *
Whom may we thank for your referral?  
Comments:   *
ENERGY LEVEL ::  

How would you rate your energy level on a scale from 1-10, 1 means extremely low and 10 means full of energy:
Do you feel like you are living in slow motion?  Yes  No
Do you feel a constant (background) tiredness or fatigue? Yes  No
Are you easily exhausted with physical activity?  Yes  No
Do you have difficulty handling stress?  Yes  No
Do you have energy swings? Yes  No
Do you feel you should have more energy? Yes  No
How long have you been feeling this way?  years
Are you run down around 4:00 p.m.?  Yes  No
Do you eat something sweet when you feel this way? Yes  No
Do you feel better at these times after you eat something sweet? Yes  No
Do you wake up tired? Yes  No
Is it difficult for you to stay up late (after midnight)? Yes  No
Do you get very tired in the evening or early night? Yes  No
Do you have difficulty recovering after having stayed up late night? Yes  No
Do you feel more tired when you are at rest than when you are active? Yes  No
   
WEIGHT CONTROL ::  
Have you had any significant weight gain?  Yes  No
How many pounds?  lbs
What year did it start?
Do you feel you put on weight easily? Yes  No
Do you have difficulty losing weight? Yes  No
How long have you had this problem? 
Do you put on weight around your waist? Yes  No
Do you put on weight around your thighs and buttocks? Yes  No
Do you have a flabby abdomen or a “spare tire”? Yes  No
Are you pear-shaped?  Yes  No
Is your upper abdomen distended? Yes  No
Is your lower abdomen distended? Yes  No
Do you suffer from constipation? Yes  No
   
TEMPERATURE SENSITIVITY ::  
Are you sensitive to cold? Yes  No
Do your hands and feet feel cold? Yes  No
How long have you experienced this?  years
Do you get chills easily? Yes  No
Do the palms of your hands or feet perspire unusually? Yes  No
How long have you experienced this?  years
Do you have decreased perspiration? Yes  No
How long have you experienced this?  years
   
MOOD AND MEMORY ::  
Are you ever anxious, nervous or irritable? Yes  No
Do you lose self-control? Yes  No
 Do you have difficulty making decisions or setting goals  Yes  No
If yes, how long have you been this way?
Do you tend to isolate yourself? Yes  No
Are you intolerant of noise? Yes  No
Do small things set you off? Yes  No
Have you noticed a decrease in mental sharpness? Yes  No
Do you have a poor short-term memory? Yes  No
Do you have trouble concentrating? Yes  No
Are you less self-confident now? Yes  No
Do you ever feel discouraged, blue or depressed?  Yes  No
If yes, what percentage of the time?
How long have you felt this way?  years
Do you or have you ever taken antidepressants?  Yes  No
If yes, which ones?
If yes, between what ages?
   
HAIR ::  
Do you have fine hair or coarse hair?
How long have you had this type of hair? years
Are your eyebrows or eyelashes thinning? Yes  No
Do you have hair loss or thinning of hair on your head? Yes  No
Do you have dry, thick, brittle hair? Yes  No
Does your hair grow slowly? Yes  No
Do you have less armpit hair? Yes  No
Do you have less pubic hair? Yes  No
Is your hair graying? Yes  No
Is your hairline receding?  Yes  No
Is it receding on the sides of the forehead? Yes  No
Are you losing your hair on top of your head? Yes  No
   
SKIN ::  
Do you have fine lines or crow’s feet at the side of the eyes? Yes  No
Do you have lines on your forehead? Yes  No
Does the skin of your face look puffy, pale or doughy? Yes  No
Is the skin on the back of your hands thin? Yes  No
Do you have lines on the side of your mouth? Yes  No
Do you have dry skin? Yes  No
If yes, since when? years
Do you have rosacea (redness on the nose and cheeks)? Yes  No
Do you have eczema, psoriasis or other rashes? Yes  No
Do you have age spots? Yes  No
Do you have thin, vertical wrinkles above your lips? Yes  No
Do your cheeks sag? Yes  No
Are your nails brittle? Yes  No
Do you have acne? Yes  No
   
EYES ::  
Do you have swelling or puffiness around your eyes or your face in the morning? Yes  No
Do you have swollen eyelids in the morning? Yes  No
Do you have dark circles under your eyes? Yes  No
How long have you had any of these problems? years
Does the swelling occur often? Yes  No
Do your eyes feel dry? Yes  No
Do you see as brightly as before? Yes  No
Do you wear corrective lenses of any sort? Yes  No
   
MUSCULO-SKELETAL ::  
Do you feel your muscles are flabby or slack? Yes  No
Do your joints get stiff in the morning? Yes  No
Do you have arthritis? Yes  No
If yes, where?
Do you have osteoarthritis of the hips? Yes  No
Do you have muscular pain? Yes  No
If yes, where?
Do you have bone loss or osteoporosis? Yes  No
Do you suffer from low back pain? Yes  No
Are your exercise work-outs less effective? Yes  No
   
SLEEP ::  
How many hours do you sleep each night, on average?
Do you feel you need a lot of sleep? Yes  No
Do you have trouble falling asleep at night? Yes  No
Is your mind filled with thoughts as you are trying to go to sleep? Yes  No
Do you wake up during the night? Yes  No
Can you go back to sleep easily during the night? Yes  No
Do you have nervous, anxious or restless sleep? Yes  No
Do you have a tendency to go to bed late and wake up late in the morning? Yes  No
Do you have difficulty waking up in the morning? Yes  No
Do you wake up too early with a heavy head in the morning? Yes  No
When you get up in the morning, are you rested? Yes  No
Do you take something to help you sleep?
 Yes  No
If yes, what do you use?
   
SOCIAL HISTORY ::  
Do you use tobacco? Yes  No
How often and how much?
Do you consume alcohol? Yes  No
Do you use caffeine? Yes  No
   
Medical Conditions/Diseases/Testing ::  
Do you exercise at least once a week? Yes  No
How do you rate your energy level? High  Fairly High  Low Poor 
How do you rate your stress level? High  Tolerable  Good Ideal
How often do you exercise every week? Once  Twice  Three times or more 
Overall how would you rate your health? Excellent     Good  Fair Poor 
What type of exercise do you do? Aerobic Anaerobic /Strengthening Both
   
Do you have any medical conditions? Please check all that apply to you.
  Cancer Depression Headaches/migraines
  Lung condition /Asthma Heart disease
  Blood Clotting Problems High Blood Pressure
  Arthritis or joint problems High Cholesterol or lipids
  Diabetes Hormonal Related Issues
  Immune system disorders Thyroid disease
  Others Ulcers Epilepsy
Have you ever been diagnosed with a thyroid disorder? Yes  No
If yes, year diagnosed. year
Are you Hyperthyroid (high) or Hypothyroid (low)? Hyperthyroid   Hypothyroid
Do you or have you ever taken thyroid medication? Yes  No
If yes, how long?
If yes, what brand and dose?  mg how often?
If not at this time, what year did you quit taking medication? year
   
Your Physicians ::  
Doctors’ Names:
Specialty:
Address:
Phone:
Past Surgical History:
Surgery:
Year:
Surgeon:
Past Diagnostic Investigation
Year 
Test
Result 
   
Current Prescription Medication(s) ::  
Medication Name
Strength
Date Started
How often per day
   
List Hormones Previously Taken ::  
Date Started
Date Stopped
Reason
   
Over-the-counter (OTC) meds: Please check all products that you use occasionally or regularly ::
  Acetaminophen (example: Tylenol)
  Antacids
  Antidiarrheals 
  Antihistamine product
  Aspirin
  Combination product (cough + cold reliever) 
  Cough suppressant
  Diet aids/ weight loss products 
  Ibuprofen (example: Motrin®)
  Ketoprofen
  Naproxen (example: Aleve®)
  Others
  Pain reliever
  Sleep aids
   
Nutritional/Natural Supplements: Please identify and check the products you are using ::
  Enzymes 
  Herbs 
  Minerals 
  Nutrition/protein supplements
  Others
  Vitamins 
   
Allergies: Please check all that apply ::  
  No known allergies Nitrate allergies
  Aspirin Penicillin
  Codeine Pet allergies
  Dye allergies Seasonal(pollen)allergies
  Food allergies Sulfa drug
  Morphine Others
Please describe the allergic reaction you experienced and when it occurred?
   
FAMILY HISTORY ::  
Do you have family history of any of the following? (Relation with the family member)
Breast Cancer  Yes  No  Family member(s)
Depression Yes  No  Family member(s)
Diabetes Yes  No  Family member(s)
Fibrocystic breast Yes  No  Family member(s)
Heart Disease Yes  No  Family member(s)
Obesity Yes  No  Family member(s)
Osteoporosis Yes  No  Family member(s)
Ovarian Cancer Yes  No  Family member(s)
Prostate Cancer Yes  No  Family member(s)
Skin Conditions Yes  No  Family member(s)
Uterine Cancer Yes  No  Family member(s)
OTHERS
   
Personal History ::  
Do you feel less confident and more hesitant? Yes  No
Does you beard grow more slowly now? Yes  No
Are your breasts getting fatty? Yes  No
Do you have hot flashes and sweats? Yes  No
Do you lack sexual desire? Yes  No
Have you lost attraction towards your partner? Yes  No
Do you feel like making love less often than you used to? Yes  No
Is sexual intercourse as pleasurable as it used to be? Yes  No
Do you feel your sexual performance is poorer than it used to be? Yes  No
Does your penis seem less sensitive? Yes  No
Has your penis changed in dimension? Yes  No
Are you able to obtain an erection? Yes  No
Are you able to maintain an erection? Yes  No
Are your erections firm enough? Yes  No
Are you able to achieve orgasm? Yes  No
Have you or do you use medication for erectile dysfunction, such as Viagra? Yes  No
   
Home |

Copyright 2008 - 2010. Amaya Clinic. All rights reserved.