Hormone Treatment Medical History Questionnaire

Hormone Medical History Questionnaire

TRT, Peptides, Thyroid, Female Hormones, Eclomiphene
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Gender*
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Patient E-Mail*
example@example.com
Patient Medical History
Please list any drug allergies
Have you ever had (Please check all that apply)*

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaAcneDry SkinOily SkinSTDs
Family History*

Any blood related family with prostate cancer?Any blood related family with diabetes?Any blood related family with cardiovascular disease?
Other illnesses:
Please list any Operations and Dates of Each
Please list your Current Medications*
Enter N/A if none.
Symptoms
Do you have a decrease in libido (sex drive)?*

YesNo
Has your energy level declined?*

YesNo
Have you lost self-confidence, motivation, or initiative?*

YesNo
Do you have a decrease in strength and/or endurance?*

YesNo
Have you noticed a decreased "enjoyment of life?"*

YesNo
Are you sad and/or grumpy?*

YesNo
Have you noticed a recent deterioration in your ability to play sports or work out?*

YesNo
Are you falling asleep after dinner?*

YesNo
Has there been a recent deterioration in your work performance?*

YesNo
Do you have a lack of energy?*

YesNo
Include other comments regarding your Medical History
Schedule the Consult*
Provider Consult - The consult provides access to treatment for 365 Days.*
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Hormone Medical History Questionnaire

Patient Medical History

Symptoms