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KESPARA MEDICAL CENTER
22 Meridian Rd, Suite 10 Edison, NJ 08820
22 Meridian Rd, Suite 10 Edison, NJ 08820
Pullin Patel,MD
Internal Medicine
Ph:(732) 243-9808
Fax:(732) 791-5765
Health Assessment For Men
 Name:
Email:
Date:
Irritability
Sleep Problems
Increased need for Sleep
Irritability
Nervousness
Anxiety
Depressed mood
Exhaustion/lacking vitality
Declining Mental Ability/Focus/Concentration
Feeling you have passed your peak
Feeling burned out/ hit rock bottom
Decreased muscle strength
Weight gain/belly fat/inability to loose weight
Chest development
Shrinking Testicles
Rapid hair loss
Decrease in beard growth
New Migraine Headaches
Decreased desire/libido
Decreased morning erections
Decreased ability to perform sexually
Infrequent or absent ejaculations
No results from Ed Medications
Family History
Heart Disease
Diabetes
Osteoporosis
Alzeheimr's Disease
Symptoms(please check mark)
Never
Mild
Moderate
Severe
Fatigue
Decline in general well being
Joint pain/muscle ache
Excessive Sweating
Print Patient's Name:
Date: