Men's Health Medical Questionnaire

Prepare a first men's health visit with a complete history. It gathers personal and contact details, tobacco and alcohol use, hormonal and urinary symptoms, sleep, diet, medications, and personal and family medical history.

Use this template

In the Claude connectors directory

Full name

First Name

Last Name

Date of birth

Gender

Address

Street Address

City

State / Province

ZIP / Postal Code

Email

Phone number

Emergency contact

First Name

Last Name

Emergency contact phone

Primary care physician

First Name

Last Name

Physician's phone

Insurance card

Max 10 MB per file

Referred by

First Name

Last Name

Reason for visit: what would you like help with?

Age

Height

Weight

Do you use, or have you ever used, tobacco (cigarettes, cigars, loose leaf, vape)?

Yes, currently Yes, but I quit Never

How much per day? Since when? If you quit, when?

Do you drink alcohol?

Yes, regularly Occasionally No

How many drinks per week?

Do you have, or have you ever had, loss of libido?

Yes No

Give the date of onset and details

Do you have, or have you ever had, stamina decrease?

Yes No

Give the date of onset and details

Do you have, or have you ever had, weight gain?

Yes No

Give the date of onset and details

Do you have, or have you ever had, muscle building difficulty?

Yes No

Give the date of onset and details

Do you have, or have you ever had, acne?

Yes No

Give the date of onset and details

Do you have, or have you ever had, hair thinning/loss?

Yes No

Give the date of onset and details

Do you have, or have you ever had, headaches/migraines?

Yes No

Give the date of onset and details

Do you have, or have you ever had, fatigue?

Yes No

Give the date of onset and details

Do you have, or have you ever had, mood changes?

Yes No

Give the date of onset and details

Do you have, or have you ever had, irritability?

Yes No

Give the date of onset and details

Do you have, or have you ever had, forgetfulness?

Yes No

Give the date of onset and details

Do you have, or have you ever had, difficulty concentrating?

Yes No

Give the date of onset and details

Do you have, or have you ever had, joint tenderness?

Yes No

Give the date of onset and details

Do you have, or have you ever had, breast tenderness?

Yes No

Give the date of onset and details

Do you have, or have you ever had, urgency/hesitancy/change in urinary stream?

Yes No

Give the date of onset and details

Do you have, or have you ever had, nocturia (urination at night)?

Yes No

Give the date of onset and how many times per night

Do you have, or have you ever had, erectile dysfunction?

Yes No

Give the date of onset and details

Do you have, or have you ever had, other symptoms you would like to share with the doctor?

Yes No

Give the date of onset and details

Have you had any surgeries?

Yes No

List all surgeries with dates

Have you had a PSA test?

Yes No Not sure

List your PSA level and test date

Average hours of sleep per night

Fewer than 5 5-6 7-8 More than 8

Do you have trouble falling asleep?

Yes No

Do you feel rested when you wake up?

Yes No

Do you snore?

Yes No

Do you use sleep aids?

Yes No

Please explain

Have you ever had a nutrition consultation?

Yes No

Have you changed your eating habits for health reasons?

Yes No

Please describe

Are you currently on a special diet or nutrition program?

Yes No

Summarize your eating habits

Summarize your exercise routine

Patient declaration

Signature

Sign here

Date

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