Female Consultation Form

HOWARD HEALTH AND WELLNESS

COREY HOWARD, MD, FACP, FMNM, ABAARM
Board Certified, Internal Medicine

Board Certified, Anti-Aging, Functional and Regenerative Medicine

1048 Goodlette Road, Suite 101, Naples, FL 34102

O:239 331-2285 F: 239 331-2347
All of your information will remain confidential between you and Dr. Corey Howard.

Please take your time filling out this questionnaire completely and honestly.
PATIENT DETAILS
Full Name

First NameLast Name
Birth Date:

MonthDayYear
E-mail*
SYMPTOMS OF ANDROPAUSE

(LOW TESTOSTERONE)
Check if you have ever had the following:

FatigueDepression or low moodIrritabilityAnxiety or nervousnessLoss of memory or concentrationLoss of sex drive or libidoLoss of erections or problems during sexDecreased intensity of orgasmsWeight gainBackache, joint painsLoss of fitnessDecrease in job performanceFeeling over stressedDecline in physical abilitiesBone lossElevated cholesterolIncreased risk of heart diseaseOther
Additional information related to low testosterone symptoms you would like us to know:
ALL PATIENT INFORMATION IS HANDLED UNDER THE HIPAA PRIVACY ACT

THIS FORM IS CONFIDENTIAL AND HIPAA APPROVED
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HOWARD HEALTH AND WELLNESS