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 Name Last Name
Birth Date:

Month Day Year
E-mail *
SYMPTOMS OF ANDROPAUSE

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

Fatigue Depression or low mood Irritability Anxiety or nervousness Loss of memory or concentration Loss of sex drive or libido Loss of erections or problems during sex Decreased intensity of orgasms Weight gain Backache, joint pains Loss of fitness Decrease in job performance Feeling over stressed Decline in physical abilities Bone loss Elevated cholesterol Increased risk of heart disease
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