Do you have a history of Erectile Dysfunction? Have you had a PSA test?

Date of most recent PSA? (MM/DD/YYYY) Result of your most recent PSA:

Do you have a history of Testicular Pain? Do you have a history of Testicular Enlargement? Do you have a history of Hernia?

Do you receive periodic mammograms?

What was the date of your last mammogram? What were the results? --None-- Clear Normal Abnormal

Are you in one of the following menopause stages? --None-- Does Not Apply Pre Peri Post Are you pregnant or breast-feeding?

Has any family member suffered from any of the following conditions?

Asthma: --None-- Yes No I Don't Know Select if it was a cause of death Cancer: --None-- Yes No I Don't Know Select if it was a cause of death Diabetes: --None-- Yes No I Don't Know Select if it was a cause of death Epilepsy: --None-- Yes No I Don't Know Select if it was a cause of death Glaucoma: --None-- Yes No I Don't Know Select if it was a cause of death Heart Disease: --None-- Yes No I Don't Know Select if it was a cause of death High Blood Pressure: --None-- Yes No I Don't Know Select if it was a cause of death Kidney Disease: --None-- Yes No I Don't Know Select if it was a cause of death Mental Illness: --None-- Yes No I Don't Know Select if it was a cause of death Pneumonia: --None-- Yes No I Don't Know Select if it was a cause of death Stroke: --None-- Yes No I Don't Know Select if it was a cause of death Tuberculosis: --None-- Yes No I Don't Know Select if it was a cause of death