Achieve Your Weight Loss Goals with RENEW Med Spa in Springfield, MA

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Our Services
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Contact Us

Call /Text (413) 438-5737

Men's Health Questionnaire

Name:

Phone:

Email:

How much exercise do you get regularly?

Sedentary

Mild Exercise

Moderate Exercis

Are you dieting?

yes

no

Please describe your alcohol intake:

Do you use tobacco? How much?

Do you use any recreational or street drugs? If so, what?

Are you sexually active?

Yes

No

During the last 3 months, how often did you make yourself vomit as a means to control your weight or shape?

Yes

No

Have you been diagnosed with HIV?

Yes

No

Do you have to get up to urinate at night?

Yes

No

Do you have discomfort with urination?

Yes

No

Has the force of your urination decreased?

Yes

No

Have you had any kidney, bladder, or prostate infections within the last 12 months?

Yes

No

Do you have any problems emptying your bladder completely?

Yes

No

Do you have problems achieving or maintain an erection?

Yes

No

Are your erections softer than they used to be?

Yes

No

Do you have ejaculation issues?

Yes

No

Any testicle pain or swelling?

Yes

No

Date of last prostate and rectal exam

Please explain any yes answers from the previous questions or tell us anything else you would like us to know:

Free Text

Other recent problems:

Please check if you have any additional issues and briefly explain:

Skin

Head/Neck

Ears/Throat/Nose

Lungs

Chest/Heart

Joint/Muscle/Back

Gastrointestinal

Bladder

Mental health

Athletic performance

Recent changes in weight

Recent changes in energy levels

Recent changes in ability to sleep

Recent changes in libido or erection quality

Recent changes in anything else

Not applicable

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CONTACT INFORMATION

413-438-5737 Text or call welcome

renewweightlossLLC@gmail.com

235 Chestnut st, Springfield, MA

BUSINESS HOURS

Saturday - 10AM to 6PM

Monday - 9AM TO 3:30PM

Additional evening weekday hours can be added if necessary.

CONTACT INFORMATION

renewweightlossLLC@gmail.com

235 Chestnut st, Springfield, MA

BUSINESS HOURS

Saturday - 10AM to 6PM

Monday - 9AM TO 3:30PM

Additional evening weekday hours can be added if necessary.

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