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Andropause Symptom Questionnaire

FULL NAME

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TELEPHONE/ EMAIL

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ADDRESS

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HOW DID YOU HEAR ABOUT US? 

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Payment Method: 

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DOB/ CURRENT AGE

 

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NATIONALITY 

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WEIGHT/ HEIGHT/ BMI 

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BLOOD PRESSURE (reading if known)

WHAT ARE YOUR MAIN CONCERNS?

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ARE YOU USING ANY HORMONE THERAPY? If none, please also state none

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HAVE YOU EXPERIENCED ANY headaches, migraine, clots in the blood, cardiac problem including high blood pressure, high cholesterol or diabetes in the past?

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DO YOU HAVE ANY FAMILY HISTORY OF prostate, testicular, colon cancer or any other cancers? Please state the relative and age of relative if applicable

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DO YOU HAVE ANY FAMILY HISTORY OF Diabetes,High Blood Pressure,Heart Disease,Autoimmune Disease,Skin Disease,Allergies,High Cholesterol,Breathing Difficulty,Clots in the blood/ deep vein thrombosis? Please state a relative and age of relative if the answer is yes

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HOW MUCH YOU ARE TROUBLED BY ANY OF THESE SYMPTOMS AT PRESENT? Please specify
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Rare
Mild
Frequent
Severe
Fatigue, tiredness or loss of energy
Decrease in physical stamina
Loss of early morning erection
Erection or potency problems
Loss of interest in sex/ loss of libido
Feeling tense, nervous or irritated
Feeling of depression with loss of interest in most things
Feeling emotional
Being/ feeling hyperactive
Increased anger or bad temper
Difficulty in sleeping
Memory problems
Attacks of panic or anxiety
Difficulty in concentrating
Heart beating quickly or strongly
Increase in waist size – weight gain
Increased fat distribution in chest area or hips
Increased in aches, joint and muscle pains
Dry skin on face or hands
Pressure or tightness in head or body
Tinnitus (ringing or buzzing in ears)
Headaches
Pins and needles in any part of the body
Breathing difficulties

ANY MEDICAL CONDITIONS IN THE PAST? Please select the right answer for you

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Yes
No
Diabetes
High Blood Pressure
Heart Disease
Skin Disease
Allergies
Autoimmune disease
High Cholesterol
Breathing Difficulty
Clots in the blood/ Deep vein thrombosis
Cancer

ARE YOU CURRENTLY ON ANY MEDICATION/ SUPPLEMENTS? Please specify

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DO YOU SUFFER FROM THE FOLLOWING? If yes, please specify

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Yes
No
Bloating
Tiredness
Irritability
Headaches
Depression
Aching joints
Dry skin
Weight-gain/ Weight-loss
Cold feet & hands
Poor memory
Constant forgetfulness
Mood changes
Stress
Any other bodily change/s

HAVE YOU BEEN DIAGNOSED WITH ANY OF THE FOLLOWING?

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Yes
No
Prostate cancer
Hypertension
Diabetes
Cardiac issues
Urinary incontinence
Any other bodily change/s

LIFESTYLE & EATING HABITS

BREAKFAST/ LUNCH/ DINNER
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HOW MUCH WATER DO YOU DRINK? Please specify amount per day

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DO YOU DRINK ANY other stimulates ie. coffees, teas, energy drinks etc.?

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DO YOU SMOKE? If so, how often, how many cigarettes of grams of tobacco if rolls

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WHAT ARE YOUR SLEEPING HABITS? Please describe

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DO YOU TAKE ANY SUBSTANCES ie. hard drugs?

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HOW MUCH ALCOHOL INTAKE i.e. units weekly?

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SUPPLEMENTS INTAKE: what kinds, brands?

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SPORTS: types/ how often?

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MEDITATION/ BREATHWORK?

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OTHER COMMENTS:

Please note that it is vital for us to receive your completed Menopause Symptom Questionnaire with any additional medical history information/ examination/ results you may wish to provide our medical team


m. +971 55 545 0797                                               e. info@medi-gyn.com

t. +971 4 566 2615                                                    ig. @medi_gyn_center

t. +971 52 200 5011                                                  w. www.medi-gyn.com

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