BioTE & Hormone Checklist for Men
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient ID # (existing patients only)
Email (potential new patients only)
example@example.com
Phone Number (potential new patients only)
Please enter a valid phone number.
Format: (000) 000-0000.
Low testosterone and andropause related symptoms - please click based on how you are feeling currently.
Rows
Never
Mild
Moderate
Severe
Decline in general well being
Depressive mood
Anxiety/feeling nervous
Mood changes/irritability
Memory issues
Declining Focus/Concentration
Decreased libido or sex drive
Decreased morning erections
Decreased ability to perform sexually
Infequent or absent ejaculations
No results from E.D. medications
Shrinking testicles
Sleep problems
Increased need for sleep
Exhaustion/fatigue/lacking vitality
Feeling you have passed your peak
Feeling burned out/hit rock bottom
New migraines headaches
Weight gain
Unable to lose weight
Increased belly fat
Breast development
Rapid hair loss
Decrease in beard growth
Excessive sweating
Feeling cold all the time
Feeling hot all the time
Decreased muscle strength
Joint pain/muscle ache
Decreased exercise endurance
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