Men's Health Intake

Confidential intake for men's health concerns. Your provider will review your answers before your visit.

All evaluation and treatment — including hormone therapy or ED medications — requires clinical assessment and is not guaranteed for every patient.

What's the main reason you're scheduling? (ED, low energy, low libido, hormones, general check-in)

How long have you noticed these symptoms?

Do you experience problems with erections (getting or keeping)?

Has your sex drive decreased compared to a few years ago?

Have you noticed decreased energy, strength, or endurance?

Have you been feeling more irritable, sad, or unmotivated than usual?

Do you snore, gasp, or feel unrested even after a full night's sleep?

Current medications, supplements, or testosterone therapy (past or present)

Medical history (diabetes, blood pressure, cholesterol, cardiac, prostate, depression)

Have you had bloodwork in the last 12 months?

What would a good outcome look like for you?

Your Information

So we can match this to your chart and follow up.

Full name *Email *PhoneDate of birthAnything you'd like the provider to know?

Submitted securely. Used only for your care.

A-Nu Health · (312) 796-2646 · info@a-nuhealth.com — These responses are informational and reviewed by your provider. Not a diagnosis. If you are in crisis, call or text 988 or call 911.