• Testosterone/Enclomiphene Initial Intake Form

    Testosterone/Enclomiphene Initial Intake Form

    Amber Tomse, APRN
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
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  • Please answer these questions truthfully and to the best of your knowledge. This will allow us to design a treatment plan specifically designed for you. Your honest answers are greatly appreciated. If it does not apply, write N/A. 

     

  • Personal Health History

  • Health Habits

  • Exercise*
  • Are you dieting?*
  • Are you sexually active?*
  • Any discomfort with intercourse?*
  • Have you been diagnosed with HIV?*

  • Family Health History

  • Please describe your family health history. Please include conditions such as prostate cancer, heart attacks, stroke, diabetes, high blood pressure etc. Please also include their age or if they are deceased.*

  • Mental Health

  • Do you have anxiety problems?*
  • Do you feel depressed?*
  • Do you have problems with eating or your appetite?*
  • Do you feel unmotivated in life?*
  • Do you have trouble sleeping?*

  • Men Only

  • Do you have to get up to urinate at night?*
  • Do you have discomfort with urination?*
  • Has the force of your urination decreased?*
  • Have you had any kidney, bladder, or prostate infections within the last 12 months?*
  • Do you have any problems emptying your bladder completely?*
  • Do you have problems achieving or maintaining an erection?*
  • Are your erections softer than they used to be?*
  • Do you have ejaculation issues?*
  • Any testicle pain or swelling?*
  • Date of last prostate and rectal exam*
     / /

  • Other recent problems:

    Please check if you have any additional issues and briefly explain:

  • Please rate each problem from a scale to 1-10, with 1 being never and 10 being often:

  • Low Mood/Depression
    Irritability
    Anxiety
    Anger
    Discouragement
    Decreased interest in activities or relationships
    Decreased productivity at work
    Decreased motivation/drive/initiative
    Concentration problems
    Memory Problems
    Foggy thinking
    Lower libido/sex drive
    Erection problems
    Increased Fatigue
    Decrease in muscle mass
    Decrease in athletic performance
    Muscle soreness/fatigue
    Decrease in strength
    Joint Problems
    Elevated blood pressure
    Blood sugar problems
    Sweet/carb cravings
    Caffeine Cravings
    Increased fat on hips/abdomen/thigh/chest
    Weightloss
    Weight gain
    Hair loss
    Anything else you would like to mention


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