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Hot Springs, AR: (501) 547-9475

Bentonville, AR: (479) 278-4206

Request Appointment

,

Bentonville, AR

(479) 278-4206

Home
Health and Wellness Services
Request Appointment
Videos
About
- Reviews
- Blog
Forms
- Male Health History
- Female Health History
Locations
- Hot Springs Location
- Bentonville Location

Male Health History

Restoration Health Care

Male Health History Form

Please fill out and submit this male health history form prior to your initial appointment at Restoration Health Care. Feel free to call us in Hot Springs or Bentonville if you have any questions.

Male Health History Form

1) Patient’s legal name:*

2) Date of birth:*

3) Street address:*

4) City:*

5) Zip:*

6) Phone number:*

7) Email:*

8) Drug allergies:*

9) Name of insurance:*

10) Policy holder's name:*

11) Insurance policy number:*

12) Current weight:*

Free Text

Use the following scale for questions 13-19: a rating of 1-4, 1 being mild through 4 being severe

13) Rate: Lack of energy or feelings of fatigue:*

1

2

3

4

14) Rate: Feelings of depression:*

1

2

3

4

15) Rate: Erection or potency problems:*

1

2

3

4

16) Rate: Loss of motivation:*

1

2

3

4

17) Rate: Decrease in libido:*

1

2

3

4

18) Rate: Decrease in physical stamina:*

1

2

3

4

19) Rate: Increased irritability or bad temper:*

1

2

3

4

20) History of cancer, if so, what kind?*

Yes

No

List cancer:*

21) History of high blood pressure?*

Yes

No

22) History of diabetes?*

Yes

No

23) List current problem or concerns:*

24) Any surgeries, if so, what kind?*

Yes

No

List surgeries:*

25) List current medication:*

Thank you for contacting us.
We will get back to you as soon as possible.

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Hot Springs location

,

(501) 547-9475

Location Details

Bentonville location

240 S Main St

Bentonville, AR 72712

(479) 278-4206

Location Details

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