Physical FormFor staff use only. Step 1 of 3 - Patient Information 0% PERSONAL INFORMATIONName(Required) First Last Today's Date(Required)Today's Date MM slash DD slash YYYY Date of Birth(Required)Date of Birth MM slash DD slash YYYY Sex(Required)Sex Your main concerns or questionsWhat are your main concerns or questions you would like to have answered by a healthcare provider at Prime Medical Group? REVIEW OF SYMPTOMSConstitutionalConstitutional Fevers/sweats/chills Weight loss/gain Fatigue / weakness Appetite Changes Select AllEndocrineEndocrine Cold/Heat Intolerance Thinner hair Decreased libido Erection difficulties Select AllSkin/BreastSkin/Breast Rash Acne Nipple Sensitivity/pain/lumps Select AllEyesEyes Drainage/pain/redness Select AllGastrointestinalGastrointestinal Heartburn/reflux Nausea/vomiting/diarrhea Blood in stool Pain in abdomen Select AllNeurologicalNeurological Headaches Numbness/tingling Select AllEars/Nose/ThroatEars/Nose/Throat Difficulty hearing Seasonal allergies Trouble swallowing Select AllPsychiatricPsychiatric Anxiety/stress Depressed mood Decreased motivation Problems sleeping Select AllCardiovascularCardiovascular Chest pain/tightness Palpitations Ankle swelling Problems sleeping Select AllGenito-urinaryGenito-urinary Pain/blood with urinating Night urination Decreased force of stream Testicular Shrinkage Select AllBlood/lymphaticsBlood/lymphatics Unusual bruising/bleeding Select AllRespiratoryRespiratory Cough/wheeze Coughing anything up Shortness of breath Select AllMusculoskeletalMusculoskeletal Muscle/joint aches or pain Joint swelling Select AllOtherOther Brain fog/concentrating Memory Longer recovery time Select AllOther:Other:PERSONAL MEDICAL HISTORYDo you have a personal history with any of the following? Heart Disease (MI/stroke/arrhythmia High blood pressure Diabetes High cholesterol Asthma COPD/Emphysema Kidney disease Prostate problems Sleep apnea Thyroid problems Cancer No current medical conditions Select AllMedication HistoryPlease indicate the medications, vitamins and supplements you are currently taking. Include both prescription and over-the-counter. Medication/Vitamin/SupplementDoseFrequencyDate StartedPrescriber Add RemoveMedicine Allergies and reaction:Please list any medicine allergies and reactions you may have. Add RemoveSurgical HistoryPlease list date, location and type of surgery/surgeries previously had. DateLocationType Add RemoveHospitalization HistoryPlease list date, location and reason for previous hospitalization(s).DateLocationReason Add RemoveLast testosterone injection prior to labs:Last testosterone injection prior to labs: Currently on tx for:Currently on tx for: Social HistorySocial History Alchohol Tobacco Black market steroids Marijuana Opiod use Do you exercise? If yes, how often?Do you exercise? If yes, how often? Family HistoryDoes any of your immediate family members have the following conditions: 1. Heart Disease 2. Hypertension 3. Hyperlipidemia 4. Asthma/COPD 5. Stroke 6. Diabetes 7. OtherLast Physical Exam prior to today:Last Physical Exam prior to today: MM slash DD slash YYYY Vital Signs - Height (Feet)Height (Feet)Please enter a number from 1 to 9.Vital Signs - Height (Inches)Height (Inches)Please enter a number from 1 to 9.Vital Signs - Weight (lbs)Weight (lbs)Please enter a number from 0 to 500.Vital Signs - Blood PressureBlood Pressure Vital Signs - BMIBMIVital Signs - HRHRVital Signs - Temp (*F)Temp (*F)Physical Exam - AppearanceAppearance Normal Abnormal Physical Exam - IntegumentIntegument Normal Abnormal Physical Exam - HEENTHEENT Normal Abnormal Physical Exam - Chest / Lungs / HeartChest / Lungs / Heart Normal Abnormal Physical Exam - AbdomenAbdomen Normal Abnormal Physical Exam - GU / Renal / GenetaliaGU / Renal / Genetalia Normal Abnormal Physical Exam - MS / Extremities / SpineMS / Extremities / Spine Normal Abnormal Physical Exam - Neuro PsychNeuro Psych Normal Abnormal Assessment & Recommendation(s)Assessment & Recommendation(s)Health Care Provider SignatureHealth Care Provider SignatureDate Signed(Required)Date Signed MM slash DD slash YYYY Office Location(Required)Office Location Name and title of Health Care Provider(Required)Name and title of Health Care Provider Date:(Required)Date: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
