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Confidential Men’s Health Consultation Form

Compounding pharmacists can help with many health issues that affect men of all ages.

Modern technology and innovative techniques allow healthcare providers to work with pharmacists to customize medications, which provide patients with medications tailored specifically for certain needs.

If you feel as though you could use help in specific issues relating to men’s health, fill out our consultation form below or click here to print out PDF version, then fax it back or bring it in. Your privacy is a top priority. This information is secure and is guaranteed to only go directly to the pharmacists.

For your convenience you can send your forms three different ways:

  1. Fill out the online Men's Health form below and sent it straight to us in our secure submission form.

  2. Print and fill out the PDF version for Men's Health and bring it in during your appointment.

  3. Print and fill out the PDF version for Men's Health and fax it to us at 760.834.6297.

Your privacy is a top priority; this information is secure and will only go directly to the pharmacists.

 

Please complete the form below:
Fields marked with * are required.

Name *
Name
Birthdate *
Birthdate
Address
Address
Phone *
Phone
Medical History
Check one, none or more:
Please list all prescriptions and non-prescriptions that you are taking:
Please list the date you started, date you stopped, and the reason for stopping.
Symptoms
Please check the following that apply:
Fatigue
Please indicate the degree of severity:
Decrease in Muscle Mass
Please indicate the degree of severity:
Loss in Muscle Strength
Please indicate the degree of severity:
Increase in Joint and Muscle Pain
Please indicate the degree of severity:
Increase in Waist Size
Please indicate the degree of severity:
Trouble Loosing Weight
Please indicate the degree of severity:
Loss in Height
Please indicate the degree of severity:
Decrease in Sex Drive
Please indicate the degree of severity:
Difficulty in Establishing/Maintaining Full Erections
Please indicate the degree of severity:
Decrease in Spontaneous Early Morning Erections
Please indicate the degree of severity:
Change in Sleep Pattern
Please indicate the degree of severity:
Decrease in Mental Sharpness
Please indicate the degree of severity:
Trouble Concentrating
Please indicate the degree of severity:
Less Enjoyment in Personal Interests/Hobbies
Please indicate the degree of severity:
Sex Desire Level