• MALE BioTE Hormone Pellet Questionnaire

  • Date of Birth
     - -
  • Is the patient a smoker?
  • What is your activity level?    (Pick one)
  • Is the patient currently on testosterone replacement therapy?
  • Is the patient currently on thyroid medication?
  • Is the patient currently on a statin?
  • Does this patient have a personal history of prostate cancer?
  • Does this patient have a history of Hashimoto's thyroiditis?

  • Are you experiencing any (Mark All That Apply):

  • Erectile Dysfunction:
  • Fatigue
  • Loss of muscle:
  • Brain Fog:
  • Decreased Libido:
  • Depression:
  • Inability To Lose Weight:
  • Irritability / Mood Swings:
  • Decreased Energy
  • Developing Breast Tissue
  • Hot Flashes:
  • Loss of Bone:

  • FOR THE PROVIDER TO FILL OUT:

  • DATE THAT THE PATIENTS LAB WORK WAS DONE:   Pick a Date   
    Total testosterone level:      
    Estradiol Level:      
    PSA Level:      
    TSH:      
    Free T3:      
    Free T4:      or Total T4:      
    Thyroid peroxidase antibodies:      
    Vitamin D level:      
    eGFR:      
    Hemoglobin:      



  • TESTOSTERONE DOSE:      
    THYROID DOSE:      

  • Should be Empty: