WELL MALE EXAM - ENGLISH

Patient Name:

Date of Birth

To help your doctor during today's health exam, please complete items 1 through 8.

1. Age:

2. Have you had any of the following problems:

a. High blood pressure

Yes No

b. Heart disease

Yes No

c. Cancer

Yes No

d. High cholesterol

Yes No

3. Do you have any of the following problems:

a. Bothersome joint pains

Yes No

b. Sexual problems (getting and keeping erections, completing intercourse, etc.)

Yes No

c. Change in size/firmness of stools

Yes No

d. change in size,/color of a mole

Yes No

e. Sleeping poorly or having any trouble falling or staying asleep during the past month

Yes No

f. Often feeling down, depressed or hopeless during the past month

Yes No

g. Often having little interest or pleasure in doing things during the past month

Yes No

h. Difficulty with urine stream strength or flow rate

Yes No

i. Getting up frequently at night to urinate

Yes No

j. Chest pain, shortness of breath, stomach problems or heartburn

Yes No

k. Problems with falling or doing routine tasks at home

Yes No

I. Periods of weakness, numbness or inability to talk

Yes No

8. Please describe any concerns you have:

Date

Height

Weight

Overweight

Yes No

BP

If necessary

Temp

Pulse

Resp

O2 sat

Allergies

Other complaints/HPl

Physicat Exam: As indicated by past medical history (none of the following are specifically reconmended by USPSTF):

Diagnoses (#s correspond to problem list):

Plan:

Follow-Up:

Routine Visit in

For

Physical Exam in

Name

Physician Signature

Date of Birth

Chart #

Physician Name