BHRT Symptom Update--Male

Date

MonthDayYear
Date
Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Have there been any changes in any of your medications in the past year? If so, please list
Please check all symptoms of Low Progesterone:
Other Symptoms?
Check all symptoms of Low Testosterone:
If you are having headaches, how many per week?
If you are experiencing insomnia, how many times per week?
Have any symptoms become more frequent/bothersome in the past few months?
Filling out a Symptom Update Sheet gives the pharmacist permission to make dosing change suggestions to your doctor. If you do not want changes, there is no reason to fill out the sheet. If you do not want the new changes filled right away, but put "On Hold" for the next time you need them filled, please indicate below.
Put on Hold?
Should be Empty: