Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Hormone Replacement Therapy Questionnaire Enter Your Name * You Suppliments any 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 # *Age *Occupation *Marital Status *MarriedDivorcedWidowLiving with PartnerSingleEmergency Contact *Health and Background Information Primary Care Physican *Current SymtomsFatigueJoint Pain/Muscle AcheMuscle Loss or Decreased StrengthLow LibidoErectile DysfunctionSleep ProblemsWeight Gain/Belly Fat/Inability ro Lose WeightHair LossMood Changes (irritability, anxiety, depression)Other SymptionsMedical HistoryDiabetesHypertensionHeart DiseaseHigh CholesterolStroke/Heart AttackBlood Clot and/or Pulmonary EmboliHemochromatosisAny form of Hepatitis or HIVThyroid DisorderCancerElevated PSA or Prostate EnlargementChronic Liver DiseaseSleep ApneaArthritisIf any checked above, provide details below and/or add anything not listed above:Surgical HistoryCurrent Medications & SupplimentsSmoking Status *--- Select Choice ---NeverFormerCurrentList any Allergies/Intolerances *Family History List chronic illnesses for family members listed below (examples: high blood pressure, high cholesterol, diabetes, cancer, bleeding disorders, autoimmune diseases, etc.) Mother:Father:Siblings:Grandmother:Grandfather:How would you rate the stress in your life, 10 being the highest? Selected Value: 1 How do you cope with stress? *Goals for HRT?Symptom ReliefEnergy LevelsSexual HealthBone HealthMood StabilizationOther Goal(s):Have you tried HRT (Testosterine) in the past? *YesNoIf Yes to Testosterone Therapy, Method Used:OralPatchCream/GelInjectionPelletDuration of Use (if applicable):Reason for Stopping (if applicable):Previously had an allergic reaction to hormones or pellets?Any other questions or items you would like to discuss? *Questionnaire About Symptoms of Low Testosterone You 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 Consent & Acknowledgement *I understand that hormone replacement therapy has potential risks and benefits.I confirm that the information provided is accurate.Signature of Patient / Responsible Person (type your name) *DateSubmit
