MALE BioTE Hormone Pellet Questionnaire

MALE BioTE Hormone Pellet Questionnaire
Patient Name

First NameLast Name
Patient Age
Date of Birth

MonthDayYear
Date
Patient's Weight
Is the patient a smoker?

YesNo
What is your activity level? (Pick one)

LowModerateAverageHigh
Is the patient currently on testosterone replacement therapy?

YesNo
If yes to the above question, what kind?
Is the patient currently on thyroid medication?

YesNo
If yes to the above question, what kind?
Is the patient currently on a statin?

YesNo
Does this patient have a personal history of prostate cancer?

YesNo
Does this patient have a history of Hashimoto's thyroiditis?

YesNo
Are you experiencing any (Mark All That Apply):
Erectile Dysfunction:

YesNo
Fatigue

YesNo
Loss of muscle:

YesNo
Brain Fog:

YesNo
Decreased Libido:

YesNo
Depression:

YesNo
Inability To Lose Weight:

YesNo
Irritability / Mood Swings:

YesNo
Decreased Energy

YesNo
Developing Breast Tissue

YesNo
Hot Flashes:

YesNo
Loss of Bone:

YesNo
FOR THE PROVIDER TO FILL OUT:
DATE THAT THE PATIENTS LAB WORK WAS DONE:   Date
Total testosterone level:   Type a label
Estradiol Level:   Type a label
PSA Level:   Type a label
TSH:   Type a label
Free T3:   Type a label
Free T4:   Type a label   or Total T4:   Type a label
Thyroid peroxidase antibodies:   Type a label
Vitamin D level:   Type a label
eGFR:   Type a label
Hemoglobin:   Type a label
TESTOSTERONE DOSE: Type a label
THYROID DOSE: Type a label
Should be Empty: