REVERSE TRT Check-in
Let us know how you are doing this month.
Name
First Name
Last Name
What is Your Current Weight?
How much weight have you lost since starting the program?
Have you noticed any changes in your energy levels, mood, or overall wellness?
Yes
No
No change since the last check in
Have there been any issues or side effects related to your TRT treatment?
Yes
No
If Yes, please detail your side effects for Dr. Rucker here.
Have there been significant changes in your diet or exercise habits?
Yes
No
Keeping the same diet as last check-in
If yes, please describe the changes you've made.
Please rate your overall wellbeing since your last check-in? (1-10 scale)
What day of the week do you typically administer your injections?
Please Select
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What is your current dose?
Have there been any obstacles to adhering to your TRT regimen?
Yes
No
If yes, please describe.
Is there any additional support you need from us to facilitate your TRT treatment?
Are You Happy With Your Progress?
Yes
No
Too Soon To Tell
If there's anything else you'd like to share about your TRT experience, please note it here.
How many doses left do you have in your current Vial
1
2
3
4
Would you like to speak with Dr. Rucker about our Add Ons?
Nandrolone
HGC
Weight Loss Options
ADHD Programs
Hair Loss Solutions
Medical Marijuana (FL only)
Are you staying on plan for next month?
Yes
No
Not Sure
Would like to speak to my Health Liaison first.
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