Male Patients Form 4

FEMALE MALE

DIETING (INCLUDING WEIGHT WATCHERS ETC) EXERCISE SUPPLEMENTS MEDICATION NONE If OTHER, please specify:

NO If YES, I DO, please specify:

NO If YES, I HAVE, please specify:

NO If YES, I HAVE, please specify:

YES NO

No If YES, I HAVE, please specify:

YES NO

NO Yes

NO If YES, I HAVE, please specify:

NO Yes

Yes No

NO If YES, I HAVE, please specify:

YES NO If OTHER, please specify:

NO If YES, I DO, please specify:

NO If YES, I HAVE, please specify:

NO If YES, I AM, please specify frequency and dosages:

NO If YES, I HAVE, please specify frequency and dosages:

NO If YES, I HAVE, please specify:

I CONFIRM I DO NOT CONFIRM