Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.FORM #1 - Hormone Replacement Therapy Questionnaire Enter Your Name Again *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Date of Birth *Phone # *Health and Background Information Age *Gender: Male Occupation *Smoking Status *--- Select Choice ---NeverFormerCurrentList and Health Problems or Physical Limitations * noticed Have strength List any Allergies/Intolerances *Have you ever had any hormone sensitive cancer such as breast or prostrate cancer?Have you ever had blood clots or heart disease?Have you ever had liver disease?Previously had an allergic reaction to hormones or pellets?How would you rate the stress in your life, 10 being the highest? Selected Value: 1 How do you cope with stress? *What are your goals with HRT? *What part of your life do you want to improve the most? *Have you tried HRT in the past? *YesNoAny other questions or items you would like to discuss? *FORM #2 - Questionnaire About Symptoms of Low Testosterone Enter Your Name AgainYou have decrease in libidoNever (0)Average (1)Poor (2)Terrible (3)You have a lack of energyNever (0)Average (1)Poor (2)Terrible (3)You have a decrease in strength and/or enduranceNever (0)Average (1)Poor (2)Terrible (3)You are sad and/or grumpyNever (0)Average (1)Poor (2)Terrible (3)You lost heightNever (0)1-1.4 inches (1)1.5-1.9 inches (2)2 inches or more (3)You noticed a decreased "enjoyment of life"Never (0)Average (1)Poor (2)Terrible (3)Your erections less strongNever (0)Average (1)Poor (2)Terrible (3)You noticed a recent deterioration in your ability to play sportsNever (0)Average (1)Poor (2)Terrible (3)You fall asleep after dinnerNever (0)Average (1)Poor (2)Terrible (3)There's been a recent deterioration in your workNever (0)Average (1)Poor (2)Terrible (3)You have memory loss, decreased ability to concentrateNever (0)Average (1)Poor (2)Terrible (3)You have backache, joint pain, stiffnessNever (0)Average (1)Poor (2)Terrible (3)Less than 6 points - it is not likely that you have hormone deficiency 7-16 points - mild hormone deficiency 17-26 points - moderate hormone deficiency Above 27 points - severe hormone deficiency Signature of Patient / Responsible Person (type your name)DateSubmit
