Confidential Medical History Form
I REALIZE THIS MEDICAL HISTORY FORM IS SOMEWHAT LONG. HOWEVER, IT IS ABSOLUTELY NECESSARY FOR ME TO
COACH YOU ON YOUR GENERAL HEALTH. MAKE SURE TO TAKE A FEW MINUTES TO CAREFULLY AND COMPLETELY ANSWER
EVERY QUESTION. FAILING TO DO SO WILL PREVENT ME FROM HELPING YOU AS WELL AS I COULD. DO THE BEST YOU CAN-
I WILL FOLLOW-UP WITH ANY QUESTIONS I MAY HAVE. REMEMBER, THIS INFORMATION IS COMPLETELY CONFIDENTIAL.
Please initial here that you have read the above statement:
ONLY FOR 1 HOUR CONSULTATIONS- If you can have these blood tests done, our coaching session will be a lot more
productive (optional but key information that wil help customize the coaching session):
OPTIMUM REQUIRED LAB WORK
------- CAH Panel 6B (Comprehensive Screen) (10299X)
------- Estradiol- ultrasensitive [4021X](13- 54 pg/mL)
------- Testosterone, Free, Bio/Total (LC/MS/MS) Code: 14966X
------- Comprehensive Metabolic Panel w/EGFR
12 -------- Prostatic Specific Antigen (PSA)
Please send any labs and this form fil ed out to me before our consultation (email: [email protected], or fax 713-
Can you describe the primary goal and outcome that you want from this consultation?:
Where did you hear about Nelson Vergel?
Have you read “Testosterone: A Man’s Guide” or “Built to Survive” and/or watched Nelson’s videos on youtube
Marital Status (Married/Significant Other, Divorced, Single )
Have you lost weight in the past 6 month? If yes, how many pounds?
Have you gained weight in past 6 months? If yes, how many pounds?
Has your body tone changed in the past 6 months (harder, softer)?
Do you have a primary care physician? (provide name if you want)
Do you have health insurance? (very helpful information)
When was your last complete physical examination?
(FOR OVER 40) Did you have your prostate examined by digital rectal exam?
(FOR OVER 40) Did you have your PSA checked?
If answer to above question is NO, have you taken testosterone in the past? How long and when did you last stop?
PAST MEDICAL HISTORY
Please indicate if you now have, or have EVER had:
PAST SURGICAL HISTORY
Have you ever been hospitalized (other than for the above mentioned surgeries?
Have you had exposure to chemotherapy or radiation?
FAMILY MEDICAL HISTORY
Have your brothers and/or sisters, parents or grandparents
, ever had (Please tell which family member(s)?
How many drinks do you typically have in a week?
Do you use any il icit substances (get high)- confidential and important?
REVIEW OF SYSTEMS
Do you CURRENTLY have
Any tenderness or sores in your mouth or throat
Blood in your stool or black tarry stool
How many times do you get up at night to urinate ?
Have you had prostatitis (prostate/urinary infections) in the past?
If you had acne, did you take Accutane? For how long?
If on testosterone now, do you have acne?
If so, is this causing stress in your relationship?
Did you have swol en or painful nipples BEFORE you ever used steroids (for Steroid Consult only)?
Can you feel any lumps around your nipples?
Have you ever taken Propecia or Proscar (finasteride) for hair loss or prostate inflammation?
Were you losing it before you started using steroids (AAS Consult only)? If so, is it falling out more quickly
Unexplained weight loss or weight gain ? which ?
Do you consider yourself to be in good health?
Do you regularly self examine your testicles?
Tell me about your diet (The more details, the better)
Do you exercise? If yes, what type and how frequently?
Do you feel that you procrastinate a lot and do not have enough mental focus to finish projects?
Are you experiencing a lot of stress lately? For how long and why?
Do you take any prescription medications or medications bought on the internet or black market?
What supplements do you take (vitamins, minerals, neutraceuticals, etc.)? List all (with amounts or dosages) each day.
How much water do you usual y drink each day?
QUESTIONS FOR STEROID CONSULT ONLY
(for confidential information only)
Tell me, as accurately as you can which steroids you are going to take, or have taken, for THIS cycle (Anabolic Consult
How many times have you been on a steroid cycle (if any)?
How long ago was your first steroid cycle (if any)?
How long was your break before starting this cycle?
Describe your past usage, if any, of hCG, Nolvadex, Clomid, Arimidex or finasteride:
Have you ever had any problems (side effects) with any of the medications mentioned in the last question If so, please
If the answer to the above is YES, is this affecting your relationship?
Has your strength or endurance decreased?
Do you have a hard time recovering from physical activity?
Have you ever been on testosterone replacement before? If yes, what kind of product did you use and for how long?
Have you ever been diagnosed with sleep apnea via a sleep study? If yes, do you use a CPAP machine?
How many hours do you usual y sleep at night? Do you take frequent naps?
How long did it usually take for you to fall asleep during the past 4 weeks?
Is there anything that you want to add or expand upon?
The information that I will receive in the consultation is for educational purposes only, and is in no way a substitute for the
advice of a qualified health care provider. I understand that appropriate medical therapy and the use of pharmaceutical
compounds like testosterone and others should be tailored for the individual, as no two individuals are alike. I understand
that Nelson Vergel does not recommend self-medicating with any compound, as I should consult with a qualified physician
who can determine my individual situation. I understand that any use of the educational information presented to me in
the coaching session is done strictly at my own risk and no responsibility is implied or intended on the part of Nelson
Signed: _______________________________ Date: _____________________________
If you have not done so, register on my new siteand watch a Nelson’s video on testosterone in the
Curriculum Vitae Mr Andrew M. C. Thomas FRCS Consultant Orthopaedic Surgeon Name: Andrew Martin Charles THOMAS Nationality: British School: Exeter School, Exeter. University: The London Hospital Medical College Degrees and Diplomas: M.B., B.S. Training Awards and Scholarships: The John Dove Travelling Fellowship Best Poster Prize John Charnley Trust
Caledonia House, 1 Redheughs Rigg, South Gyle, Edinburgh, EH12 9DQ Tel/Fax: 0131-625-4404 Email: [email protected] Website: www.scotsac.com Membership Subscription Renewal I/We enclose my/our annual subscription for continued membership of the Scottish Sub Aqua Club (ScotSAC) for 12 months. I/we am/are member(s) of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Branch. C