PRE-SCREENING » MALE

 
Prefix: * City: *
First Name: * State: *
Middle Initial: Zip: *
Last Name: * Best Phone Number to Reach You: *
Date of Birth: * ( MM/DD/YYYY ) Best Time to Call You:  
E-mail: * Height: ( Ft )
Address 1:* Weight: ( Lbs )
Address 2:
 
 
What Are Your Chief Medical Complains? *
What Do You Expect to Achieve With an Anti-Aging Treatment? *
 
 
• BEHAVIOR NONE MILD MODERATE SEVERE
Nervous
Depressed
Stress
Irritable
Anxious
Apathy
Aggressive Behaviour
 
• MEMORY NONE MILD MODERATE SEVERE
Decreased Mental Sharpness
Mental Fatigue
Increased Forgetfulness
 
• ENERGY NONE MILD MODERATE SEVERE
Burned Out Feeling
Morning Fatigue
Evening Fatigue
Decreased Stamina
 
• HEART NONE MILD MODERATE SEVERE
Rapid Heartbeat
Heart Palpitations
Slow Pulse Rate
 
• BLOOD NONE MILD MODERATE SEVERE
High Blood Pressure
Low Blood Pressure
High Blood Sugar
Low Blood Sugar
High Cholesterol
Elevated Triglycerides
 
• SEXUAL DRIVE NONE MILD MODERATE SEVERE
Decreased Erections
Decreased Libido
Infertility Problems
 
• MUSCLES NONE MILD MODERATE SEVERE
Decreased Flexibility
Decreased Muscle Size
Sore Muscles
 
• SKIN / HAIR / NAILS NONE MILD MODERATE SEVERE
Oily Skin / Hair
Acne
Thinning Skin
Hair Dry or Brittle
Nails Breaking or Brittle
 
• ACHES / PAIN NONE MILD MODERATE SEVERE
Headaches
Increased Joint Pain
Neck or Back Pain
 
• OTHERS NONE MILD MODERATE SEVERE
Sugar Cravings
Difficulty Sleeping
Swelling or Puffy Eyes/Face
Cold Body Temperature
Numbness of Feet / Hands
Dizzy Spells
Goiter
Prostate Problems
Sensitivity to Chemicals
Bone Loss
Allergies
Hoarseness
Rapid Aging
Hearing Loss
Ringing in Ears
Weight Gain Breasts/Hips
Weight Gain Waist
Decreased Urinary Flow
Increased Urinary Urge
Constipation
Hot Flashes
Night Sweats
Decreased Sweating
 
 
Do You Smoke? *
YES   NO
Explain:
Do You Drink Alcohol? *
YES   NO
Explain:
Do You Exercise? *
YES   NO
Explain:
Do You Wake Up Hungry? *
YES   NO
Comments:
Are You Hungry at Lunch Time? *
YES   NO
Comments:
What Do You Usually Eat During the Day? *
Do You Feel Sleepy in the Afternoon? *
YES   NO
Comments:
Do You Fall Asleep Fast? *
YES   NO
Comments:
How Many Times do You Wake Up During the Night? *
Explain:
How Many Hours of Uninterrupted Sleep do You Get Per Night? *
Do You Suffer From Chronic Skin Rash? *
YES   NO
Comments:
How Did You Hear About Us? *
 
 
   

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American Institute for Smart Aging ®     www.smartagingdoctor.com     contact@smartagingdoctor.com
Address: 4850 Sugarloaf Parkway, suite 501, Lawrenceville, GA 30044     Phone: (678) 824-8604 Fax: (678) 824-8607
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