[ "When/why did you become concerned about testosterone abnormality" => "text", "When were testosterone levelsfirst measured (levels?)" => "text" ], "When testosterone was first measured had you previously taken or were taking" => [ "prescription pain medication" => ["radio" => ["yes", "no"]], "muscle building supplements or steroids" => ["radio" => ["yes", "no"]], "testosterone supplements/medications" => ["radio" => ["yes", "no"]] ], "Regarding sexual function" => [ "Haslibido (sex drive) changed" => ["radio" => ["yes", "no"]], "Has erectile function changed" => ["radio" => ["yes", "no"]], "Have you used erection medications (What? How Long? Success?) describe" => "text" ], "Regarding fertility" => [ "Do you have biological children" => ["radio" => ["yes", "no"]], "Have you needed fertility assistance for pregnancy" => ["radio" => ["yes", "no"]], "Are you hoping to have more children" => ["radio" => ["yes", "no", "maybe"]] ], "Regarding factors that may indicate a problem that can contribute to testosterone problems have you had" => [ "Abnormal timing or issues with puberty" => ["radio" => ["yes", "no"]], "History of undescended or twisted testicle" => ["radio" => ["yes", "no"]], "History of testicular trauma or infections" => ["radio" => ["yes", "no"]], "History of brain trauma, concussion, or stroke" => ["radio" => ["yes", "no"]], "History of chemotherapy or radiation therapy" => ["radio" => ["yes", "no"]], "Issues with snoring" => ["radio" => ["yes", "no"]], "Prior Sleep apnea evaluation" => ["radio" => ["yes", "no"]], "Family members with low testosterone NO/YES: (Who?)" => "text", "Family members with fertility problems NO/YES: (Who?)" => "text" ], "Regarding prostate health" => [ "Have you a rectal prostate exam NO/YES: If yes, last was when?abnormal?" => "text", "Have you had PSA blood testingNO/YES: If yes, last was when? Abnormal?" => "text", ], "PERSONAL MEDICAL HISTORY (indicate if you have the following with YEAR OF DIAGNOSIS)" => [ "High Blood if yes (Year of Diagnosis/ Details)" => "text", "High Cholesterol if yes (Year of Diagnosis/ Details)" => "text", "Heart Attack if yes (Year of Diagnosis/ Details)" => "text", "Stroke if yes (Year of Diagnosis/ Details)" => "text", "Atrial Fibrillation if yes (Year of Diagnosis/ Details)" => "text", "Celiac Disease if yes (Year of Diagnosis/ Details)" => "text", "Cancer if yes (Year of Diagnosis/ Details)" => "text", "Depression / Anxiety if yes (Year of Diagnosis/ Details)" => "text", "Kidney Disease if yes (Year of Diagnosis/ Details)" => "text", "Kidney Stones if yes (Year of Diagnosis/ Details)" => "text", "Osteoporosis if yes (Year of Diagnosis/ Details)" => "text", "Broken Bone if yes (Year of Diagnosis/ Details)" => "text", "Liver problems/Hepatitis if yes (Year of Diagnosis/ Details)" => "text", "Bleeding Problems if yes (Year of Diagnosis/ Details)" => "text", "Intestinal Problems if yes (Year of Diagnosis/ Details)" => "text", "Thyroid Problem if yes (Year of Diagnosis/ Details)" => "text", "Emphysema/COPD if yes (Year of Diagnosis/ Details)" => "text", "Asthma if yes (Year of Diagnosis/ Details)" => "text", "Smoking if yes (Year of Diagnosis/ Details)" => "text", "Alcoholism if yes (Year of Diagnosis/ Details)" => "text", "Other Problems " => "text" ], "SURGICAL HISTORY " => [ "Elevated PSA" => ["radio" => ['yes', 'no']], "Trouble passing urine" => ["radio" => ['yes', 'no']], "Taking medicine for prostate or male-pattern balding" => ["radio" => ['yes', 'no']], "History of anemia" => ["radio" => ['yes', 'no']], "Vasectomy" => ["radio" => ['yes', 'no']], "Erectile dysfunction" => ["radio" => ['yes', 'no']], "Testicular or prostate cancer" => ["radio" => ['yes', 'no']], "Prostate enlargement or BPH" => ["radio" => ['yes', 'no']], "Kidney disease or decreased kidney function" => ["radio" => ['yes', 'no']], "Frequent blood donations" => ["radio" => ['yes', 'no']], "Non-cancerous testicular or prostate surgery" => ["radio" => ['yes', 'no']], "Severe snoring" => ["radio" => ['yes', 'no']], "Taking medicine for high cholesterol" => ["radio" => ['yes', 'no']], ], "Birth Control Method" => [ "planning pregnancy in the next year" => "checkbox", "Depend on partner’s contraception" => "checkbox", "Vasectomy" => "checkbox", "Condoms" => "checkbox", "Other" => "text" ], "Activity Level" => [ "Low – sedentary" => "checkbox", "Moderate – walk/jog/workout infrequently" => "checkbox", "Average – walk/jog/workout 1 to 3 times per week" => "checkbox", "High – walk/jog/workout regularly 4+ times per week" => "checkbox" ], "SOCIAL HISTORY" => [ "Tobacco Use" => ["radio" => ["yes", "no", "quit"]], "Alcohol Use" => ["radio" => ["yes", "no", "quit"]], "Alcohol Use" => ["radio" => ["yes", "no", "quit"]], "Marital Status" => ["radio" => ["single", "married", "separated", "domestic partner", "others"]], "Sexually Active" => ["radio" => ["yes", "no", "not currently"]], "Current partner is" => ["radio" => ["yes", "no", "quit"]], "Birth control method (if applicable)" => "text", "Retired?" => ["radio" => ["yes", "no"]], "Current or Past Occupation" => "text", "Current or Past Occupation" => "text" ], "ALLERGIES" => [ "MEDICATION ALLERGIES / INTOLERANCES" => "textarea", "Have you ever had any issues with local anesthesia?" => ["radio" => ['yes', 'no']], "Do you have a latex allergy?" => ["radio" => ['yes', 'no']], "Do you have a latex allergy?" => "text", "Current hormone replacement? if yes what?" => "text", "Past hormone replacement therapy" => "text" ], "MEDICATIONS" => [ "CURRENT MEDICATIONS" => 'textarea' ], "Family history" => [ "Heart disease" => ["radio" => ['yes', 'no']], "Diabetes" => ["radio" => ['yes', 'no']], "Osteoporosis" => ["radio" => ['yes', 'no']], "Alzheimer’s/dementia" => ["radio" => ['yes', 'no']], "Breast cancer" => ["radio" => ['yes', 'no']], "Other" => "text" ], "HEALTH ASSESSMENT SYMPTOMS" => [ "Sweating (night sweats or excessive sweating)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Increased need for sleep or falls asleep easily after a meal" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Depressive mood (feeling down, sad, lack of drive)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Irritability (mood swings, feeling aggressive, angers easily)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Anxiety (inner restlessness, feeling panicked, feeling nervous, inner tension)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Sexual problems (change in sexual desire or in sexual performance)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Bladder problems (difficulty in urinating, increased need to urinate)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Erectile changes (weaker erections, loss of morning erections)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Difficulties with memory" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Problems with thinking, concentrating or reasoning" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Difficulty learning new things" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Trouble thinking of the right word to describe persons, places or things when speaking" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Increase in frequency or intensity of headaches/migraines" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Rapid hair loss or thinning" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Feel cold all the time or have cold hands or feet" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Weight gain, increased belly fat, or difficulty losing weight despite diet and exercise" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Infrequent or absent ejaculations" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], "Difficulties with memory" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']], ] ];