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Home
Our Clinic
About Me
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Client Application
Contact Us
© 2025 Holistic Male
Patient Intake Form
First name
Last name
Age
Height (ft.)
4'
5'
6'
7'
Height (in.)
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
Weight (lbs.)
Race
Country, State(province), City
Occupation
Relationship Status
Single
Married / Partnered
Sexual Orientation
Straight
Gay
Bisexual
Primary Concern
Do you have a primary care doctor?
Yes
No
List active medical diagnoses
List all Rx medications currently taking (dosage, frequency):
List all supplements (OTC) currently taking (dosage, frequency):
Have you had any major hospitalizations or surgeries?
Yes
No
If yes, please describe:
Do you have any allergies or sensitivities (food, environment, medications)?
Are you currently working with any medical or holistic professionals on your primary concern?
Yes
No
Have any medications, supplements or lifestyle changes helped?
Yes
No
If yes, please explain:
What has NOT helped that you’ve already tried?
How familiar are you with natural / holistic healing (from personal use):
Very
Somewhat
Not at all
Do you follow a specific diet?
None
Vegan
Vegetarian
Raw Food
Paleo
Keto
Atkins
Mediterranean
Whole Food
Gluten-free
Other
Please specify:
Do you struggle with maintaining a healthy weight?
Overweight
Underweight
N/A
Do you have visceral fat (aka a “beer belly”)?
Yes
No
Do you have gynecomastia (aka “man boobs”)?
Yes
No
How many meals do you eat per day (excluding snacks):
Approximate time of each meal:
How many snacks do you eat per day (in between meals):
0
1-2
3-5
5+
How many servings of vegetables do you consume on average per day:
How many glasses of water do you consume on average per day:
0
1
2
3
4
5
6
7
8
9
10
10+
How many servings of sugar (dessert, candy, can of soda pop, etc.) do you consume per day?
0
1
2
3
4
5
6
7
8
9
10
10+
Do you have any food cravings?
Sugar
Salty
Sour
Bitter
Spicy
Fatty/Creamy
Carbs
Crunchy/Crispy
Do you consume alcohol?
Yes
No
Do you use tobacco or other nicotine products?
Yes
No
Do you use cannabis?
Yes
No
Do you use any recreational drugs?
Yes
No
Do you suffer from any ongoing digestive issues?
Indigestion
Nausea
Diarrhea
Constipation
Upset Stomach
Abdominal Pain
Acid Reflux
Heartburn
IBS
Bloating
Excessive Flatulence (gas)
Foul Odor
Urine color:
Clear
Pale Yellow
Yellow
Dark Yellow
Brown
Milky
Any pain or difficulty urinating?
Pain
Burning Sensation
Weak Stream/Flow
How often do you experience a bowel movement?
Multiple Times Daily
Daily
Every Other Day
Every Few Days
Consistency of Stool (poop):
Hard/Dry
Firm (Normal)
Loose (Wipe is messy)
Watery
How many days do you exercise per week?
Never / Once
Twice / Ever other day
Daily
Do you have an occupation which requires frequent sitting or standing in place?
Yes
No
Do you use a gym?
Yes
No
What type of exercise do you do?
Aerobic
Anaerobic
How often do you spend time in greenspace (outdoors), and what do you do there?
On average, how many hours of sleep do you get per night?
What time do you usually go to bed?
Hours
Minutes
AM
PM
What time do you typically wake up?
Hours
Minutes
AM
PM
Do you have difficulty falling asleep?
Yes
No
Do you take any OTC or Rx sleep aids?
Yes
No
Do you have difficulty staying asleep?
Yes
No
Do you snore or has anyone told you that you snore?
Yes
No
Do you wake up gasping for air or choking?
Yes
No
Do you grind your teeth at night?
Yes
No
Do you experience restless legs, twitching or discomfort in your legs at night?
Yes
No
Do you suffer from nightmares or night terrors?
Yes
No
Do you wake up feeling rested?
Yes
No
Do you experience daytime fatigue or drowsiness?
Yes
No
Do you have a consistent sleep schedule 7 days a week?
Yes
No
Do you take naps during the day?
Yes
No
How would you describe your overall mental well-being?
Excellent
Good
Fair
Poor
On a scale of 1-10, how would you rate your current stress level?
1 = no stress, 10 = extreme
Do you experience any of the following?
Depression
Anxiety
Worry
Panic Attacks
Mood Swings
Do you experience chronic fatigue or low energy?
Yes
No
Do you have any brain fog or memory issues?
Yes
No
Do you suffer from any of the following:
High blood pressure
Tachycardia (rapid heard rate)
Hyperhidrosis (excessive sweating)
Cold hands/feet
Ulcers
Do you struggle with low self-esteem, body image concerns or feelings of inadequacy?
Yes
No
Do you have any past trauma or psychological concerns you would like to discuss?
Yes
No
Please describe:
Did you feel safe and nurtured as a child?
Always
Usually
Sometimes
Never
Do you practice any form of spirituality or meditation?
Yes
No
Do you have an established skincare routine and use skincare products such as facial cleanser, lotion, serum, etc?
Yes
No
Would you be interested in learning about how to improve the condition of your skin as well as anti-aging treatments?
Yes
No
Are you happy with your current skincare routine?
Yes
No
N/A
Do you experience acne, frequent breakouts or clogged pores?
Yes
No
Do you have dry, flaky or itchy skin?
Yes
No
Do you experience excessively oily or greasy skin?
Yes
No
Is your skin sensitive or reactive to any specific allergens or chemicals?
Yes
No
Do you have any chronic skin conditions
Eczema
Psoriasis
Rosacea
Dermatitis
Warts
Other
Do you regularly spend time in the sun?
Yes
No
Do you supplement with vitamin D?
Yes
No
How would you describe your current libido (sex drive)?
High
Normal
Low
None
Has your libido changed recently?
Higher
Lower
No
Do you experience difficulty achieving or maintaining an erection?
Achieving
Maintaining
No
How would you rate your ability to maintain an erection during sexual activity?
1 = very difficult 10 = no difficulty at all
Do you experience premature ejacualtion?
Yes
No
Do you experience delayed ejaculation or difficulty reaching orgasm?
Yes
No
Do you feel numbness, reduced sensitivity, or lack of pleasure during sexual activity?
Yes
No
Do you experience nocturnal erections (hard at during sleep)?
Yes
No
Upon waking up in the morning are you typically erect or flaccid (hard or soft)?
Erect
Flaccid
Do you have any concerns about sexually transmitted infections, past or present, that you’d like to discuss?
Yes
No
Please describe:
Do you experience symptoms of low testosterone?
Low energy
Chronic fatigue
Loss of muscle mass
Belly fat
Mood changes
Depression
Irritability
Brain fog
Difficulty concentrating
Lack of motivation
Low sex drive
Erectile dysfunction
Soft erections
Decreased facial or body hair growth
Check all that apply
Have you had your testosterone or hormone levels checked?
Yes
No
When were they last checked?
Are you currently taking TRT or other hormone treatments?
Yes
No
Are you using or have you ever used non-Rx steroids for bodybuilding?
Yes
No
Do you adhere to a low-cholesterol diet and/or take a statin drug?
Yes
No
What are your top three wellness goals or priorities at this time? Please be as detailed and specific as you wish.
Are there any specific wellness topics, treatments or holistic approaches you’re interested in learning more about?
On a scale of 1-10, how committed are you to making lifestyle changes to improve your wellbeing?
(1 = not ready, 10 = fully committed)
Is there anything else you would like to share or that you feel is important for me to know about your main concern?
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About Me
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