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Available Forms

New Patient Medical History Form (Male)

Patient Information

Pharmacy Information

Past Medical History

If you have selected any of the previous boxes, enter details below:

Past Surgical History


If you have been hospitalized for any reason (excluding surgeries listed above and deliveries), please describe here:


Please list your current medications, including vitamins and herbs, and their respective doses:


Please list any allergies to medications (or latex) that you may have:

Family Planning History

For above, please add details(dates of use, types or names) below:
If yes, please enter date or dates.

Family History

If you chose any of the previous options, please describe the condition and the family member's relationship to you:

Social History

type, servings/day
type, servings/day

Have you used any of the following:

If yes, servings/day and type
If yes, how much, or how many packs per day, and how many years have you been smoking?
If checked, please describe below:

Health Maintenance

Please describe each test, date it was performed, and results below:

Review of Systems

Check any of the following that you are CURRENTLY experiencing:

Please describe below:

Prior Fertility Testing

Intercourse without contraception
Describe tests, dates, and results below:
Please describe above.
* Required field