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All questions contained in this questionnaire are strictly confidential.

First Name *

Last Name *

Email *

Phone *

Street Address *

City *

Postal code *

State *

Sex assigned at birth *

Date of birth *

Height *

Weight *

Impairments: *

Physical

Visual

Hearing

Not Applicable

Personal Health History

Surgeries in the last 5 years: *

List Any Medical Problems That Doctors Have Diagnosed: *

List Your Prescribed Drugs and Over-the-Counter Drugs, such as vitamins and other supplements (Strength/Frequency) *

Allergies to Medications, Food, Environment, Bee stings etc: (Drug, Reaction You Had) *

Personal History

Are you currently experiencing or being treated for any of the following? (check all that apply) *

Personal History: If cancer, please explain *

Personal History: If Other, please explain *

Family History

Do you have a family history of any of the following? *

Family: if yes to cancer, please explain *

HRT/TRT Screening Tools

Have you ever had an adverse or allergic reaction to Testosterone or Testosterone replacement support medications ( Testosterone injectable, topical (androgel, testim, bioidentical), Clomiphene (clomid), Enclomiphene, HCG (human chorionic gonadotropin), Gonadorelin, Anastrazole (Arimadex), or to any of its ingredients? *

Yes

No

Are you currently taking or have you taken any of the following in the past - Testosterone replacement support medications ( Testosterone injectable, topical (androgel, testim, bioidentical), Clomiphene (clomid), Enclomiphene, HCG (human chorionic gonadotropin), Gonadorelin, Anastrazole (Arimadex)? *

Yes

No

If yes, Are you currently taking or have you taken any of the following in the past - Testosterone replacement support medications ( Testosterone injectable, topical (androgel, testim, bioidentical), Clomiphene (clomid), Enclomiphene, HCG (human chorionic gonadotropin), Gonadorelin, Anastrazole (Arimadex)?(which ones and what dose) *

Have you been advised to avoid hormone replacement due to a medical condition? *

Yes

No

If yes, have you been advised to avoid hormone replacement due to a medical condition? *

Have you ever been diagnosed with prostate or breast cancer? *

Yes

No

Do you have a personal medical history involving any of the following medical conditions? *

Are you taking any of the following medications? *

PATIENT CONSENT & PAYMENT

I have received information on the risks and benefits of Hormone Replacement Therapy (HRT) / Testosterone Replacement Therapy (TRT) and the treatment options recommended to me. I fully understand this information and have had the opportunity to ask any questions.

I consent to undergoing the HRT/TRT screening and, if appropriate, to receiving treatment as recommended by my healthcare provider. I understand that I may withdraw my consent at any time by informing my provider.

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