Men's HRT

'; var analyticsAutoLink = ' '; (function(i,s,o,g,r,a,m){i['GoogleAnalyticsObject']=r;i[r]=i[r]||function(){(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o), m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m) })(window,document,'script','https://www.google-analytics.com/analytics.js','ga'); ga('create', ' ', 'auto', {'allowLinker': true}); ga('send', 'pageview'); if(window.analyticsAutoLink && analyticsAutoLink != '') {analyticsAutoLink = analyticsAutoLink.replace(/ /g, '').split(/[,\n]/g);ga('require', 'linker');ga('linker:autoLink', analyticsAutoLink);}
MEN'S Questionnaire
This form is an abbreviated symptom profile.

To expedite dose recommendations, please fax to (888-454-9135) your medication profile, history and physical.

Please notate in the fax the reason you are faxing information. We want to make sure it is associated with your form.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Submitted

MonthDayYear
Date
Date of Birth

MonthDayYear
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Preferred method of contact
PHYSICIAN / PRESCRIBER
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prescriber Name
MEDICAL & SOCIAL HISTORY
Medical History - Select all that apply

Other
If you selected Cancer, what type?
Other medical condition(s)
Medications
Medication History
List all prescription and non-prescription medications you are currently taking. (Including vitamins, herbals, and supplements). Record "None" if applicable.
Drug Allergies
List all drug allergies (Including vitamins, herbals, and supplements). Record "None" if applicable.
SYMPTOMS
SELECT A BOX FOR EACH SYMPTOM that best describes how you have been feeling for the past few months.
- None - symptom not present
- Mild - present but not distressing
- Moderate - distressing, but not interfering with daily life
- Severe - very distressing, interferes with daily life
IT IS ENCOURAGED FOR THE PATIENT TO KEEP A COPY OF THIS BASELINE SYMPTOM PROFILE TO BETTER MONITOR THE PROGRESS OF THE THERAPY.
More fatigued and/or tired than usual
Decrease in muscle mass
Loss in muscle strength
Increase in waist size
Trouble losing weight
Experienced a loss in height
Decrease in sex drive
Difficulty in establishing and/or maintaining full erections
Decrease in spontaneous early morning erections
Changes in usual sleep pattern
Decrease in mental sharpness
Trouble concentrating
Experience less enjoyment in personal interests and hobbies
Comments
Please upload current picture identification (drivers license, state identification, passport, etc...)

Cancelof
Should be Empty:

MEN'S Questionnaire

PHYSICIAN / PRESCRIBER

MEDICAL & SOCIAL HISTORY

SYMPTOMS