Testosterone Initial Intake Form

Testosterone/Enclomiphene Initial Intake Form

Amber Tomse, APRN
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Drivers License/ID*

Cancelof
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
What are your goals for treatment? Do you have any specific concerns you would like to addressed? *
Please list any medical conditions you have been diagnosed with such as high blood pressure.*
Surgeries*
Hospitalizations*
Have you ever been on testosterone replacement? Please describe your history of prescribed or illicit steroid use*
List any medications or supplements you are taking:*
Please list any drug allergies you have:*
Health Habits
Exercise*

SedentaryMildModerateRegular
Are you dieting?*

YesNo
Do you use tobacco? How much?*
Please describe your alcohol intake:*
Do you use any recreational or street drugs? If so, what?*
Are you sexually active?*

YesNO
Any discomfort with intercourse?*

YesNo
Have you been diagnosed with HIV?*

YesNo
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.*

FatherMotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherPaternal GrandfatherSiblingsChildrenUnknown
Mental Health
Do you have anxiety problems?*

YesNo
Do you feel depressed?*

YesNo
Do you have problems with eating or your appetite?*

YesNO
Do you feel unmotivated in life?*

YesNo
Do you have trouble sleeping?*

YesNo
Men Only
Do you have to get up to urinate at night?*

YesNo
Do you have discomfort with urination?*

YesNo
Has the force of your urination decreased?*

YesNo
Have you had any kidney, bladder, or prostate infections within the last 12 months?*

YesNo
Do you have any problems emptying your bladder completely?*

YesNo
Do you have problems achieving or maintaining an erection?*

YesNo
Are your erections softer than they used to be?*

YesNo
Do you have ejaculation issues?*

YesNO
Any testicle pain or swelling?*

YesNo
Date of last prostate and rectal exam*

MonthDayYear
Date
Please explain any yes answers from the previous questions or tell us anything else you would like us to know:
Other recent problems:

Please check if you have any additional issues and briefly explain:
SkinHead/NeckEars/Nose/ThroatLungsChest/HeartJoint/Muscle BackGastrointestinalBladderMental HealthSexual HealthAthletic performanceRecent changes in weightRecent changes in energy levelRecent changes in ability to sleepRecent changes in libido or erection qualityRecent changes in anything elseNot applicable
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
Should be Empty:

Testosterone/Enclomiphene Initial Intake Form

Personal Health History

Health Habits

Family Health History

Mental Health

Men Only

Other recent problems:

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