Patient
DOB
Date
BP
P
R
T
HT
WT
LMP
Allergies
PMH
PSH
MEDS
SOC
FMHX
ROS Decreased Libido Fatigue Erectile Dysfunction Central Obesity Decreased Mentation (clarity of thought, memory) Weight Gain / Muscle Loss Depression
Physical Exam (check if WNL or "+" for positive and "-" for negative) Gen Skin Heent Thyroid Enlarged Nodules Check Cardio ABD GU MS Muscular Artrophy Neuro Reflexes(hypo, hyper)
Physician Name
Phone Number
Physician Signature
