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Westcoast Women’s Clinic for Midlife Health
www.westcoastwomensclinic.com
1003 West King Edward
Vancouver, BC, V6H 1Z3
Phone: 604-738-9601


Adult Male Questionnaire
Patient Name: ____________________________ Birth date(mm/dd/yy): ____/____/____ Address: ___________________________________________________________________ City: _________________________________________ Prov: _______ Postal: _______ Home Phone: _____________________Cellular_________________Work:_______________ Email: ________________________ Occupation:__________________________________________________________________ Previous Occupations: _________________________________________________________ Single _____ • Do you use tobacco? _____ Yes How much per day?_____________________ • Do you use alcohol? _____ Yes How much per day?_____________________ • Do you use caffeine? _____ Yes How much per day?_____________________ • Tea, Coffee or Chocolate? ___________________________________________________________ • Do you use illicit drugs, gamble, view pornography or engage in risk-taking activities? Yes, please describe_______________________________________________________________ No:______ • Do you drink carbonated beverages?_____ Yes How many per day? ________
Allergies:
Please check all that apply
_____ Penicillin
_____ nitrate allergy _____ no known allergies _____ food allergies _____ pet allergies
Please describe the allergic reaction you experienced and when it occurred: _____________________________
_____________________________________________________________________________
Over-the-counter (OTC) issues: Please check all products that you used occasionally or regularly.
_____ pain reliever
____ combination products (cough & cold reliever, Triaminic DM®) ____ sleep aids (Excedrin PC®, Unisom®, Sominex®, Nytol®) ____ antidiarrheals (Imodium®, Pepto Bismol®, Kaopectate®) ____ Laxatives / stool softener (Doxidan®, Correctol®) ____ Diet aids / weight loss products (Dexatrim® _____ cough suppressant (Robitussin DM®) ____ acid blockers (Tagamet HB®, Pepcid C®, Zantac 75®) _____ antihistamine (Benadryl, Chlor-Trimeton®) ____ others: __________________________________ _____ decongestant (Sudafed®)
Nutritional /Natural Supplements: Please check the products you are using & list below
_____ vitamins (multiple or single vitamins, i.e. B complex, E, C, carotene)
_____ minerals (calcium, magnesium, chromium, colloidal minerals, single minerals)
_____ herbs (Ginseng, Ginkgo Biloba, Echinacea, herbal medicinal teas, tinctures, etc.)
_____ enzymes (digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.)
_____ nutrition / protein supplements (shark cartilage, protein powders, amino acids, fish oils)
_____ others (glucosamine, etc.): ___________________________________________________________

Vitamin/Mineral

Supplement
Name Date

Describe your eating habits including the times you usually eat: (include desserts)

Breakfast
Dinner Type
What foods to you crave?


Medical Conditions / Diseases: Please check all that apply to you.
_____
_____ High cholesterol or lipids (e.g. hyperlipidemia) _____ High blood pressure (e.g. hypertension) _____ Lung conditions (e.g. asthma, emphysema, COPD) _____ Hernia(s) _____ _____ Malabsorption (diarrhea, bowel disorders)
Please describe any past medical history:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Past Surgeries:


Current Prescription Medications:

____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
How often have you taken antibiotics? ________________________________________________________


Hormones previously taken

Date Started
Date Stopped
_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
Do you have a family history of any of the following?
Enlarged Prostate


Any other family history we should know about?
_______________________________________
_________________________________________________________________________
Please indicate your symptoms for the following conditions:
ABSENT

Lifestyle Questions
1. How often do you exercise?________________________________________________
What types:_____________________________________________________________
2. During the past 12 months, how often have you felt excessive stress in your life?
Never_____ Occasionally_____ Often_____ Almost
Have you experienced any major losses in life? Yes____ No____ 3. How would you describe your health? Excellent_____ Very
Describe your problems that lead you to this consultation:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What are your goals with this consultation?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Please write down any specific questions you may have.
_________________________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
If possible, please fax or bring any recent lab work or other test results with you. Thank you!

Source: http://www.westcoastwomensclinic.com/pdf/adult%20questionaire%20-%20%20male.pdf

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Medications for reducing breast cancer risk Hui Gao, M.D., Ph.D, Harbin Medical University When healthy people take medications to reduce their risk of developing breast cancer, it is called chemoprevention. Now there are several medications available for chemoprevention; however, they all have some side effects. This article will give a brief review of these medications. What medications

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Woher kommt die Fasnacht ? Lärmiges Treiben, Guggenmusiken, verbrannte Bööggen und ausgelassene Stimmung: Dies alles und noch viel mehr ist Fasnacht, so wie wir sie kennen. Doch kaum einer weiss, wieso wir jedes Jahr dieses Fest so feiern. Auf der Such nach den Ursprüngen stösst man bis in das alte Ägypten vor. Eigentlich verdanken wir die Fasnacht dem altägyptischen Sonnengott Ra.

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