Male Patient Hormone Questionnaire
Today's Date
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Month
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Day
Year
Date
Date of Birth
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Month
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Day
Year
Date
Full Name
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First Name
Last Name
Please check all that apply to you:
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I am sexually active.
I want to be sexually active.
I have completed my family.
I have no plans to attempt conception within 2 years.
I have used steroids in the past for athletic purposes.
I have had issues with anesthesia. If yes, please explain below.
I am currently on hormone replacement therapy. If yes, please explain below.
In the past, I was on hormone replacement therapy. If yes, please explain below.
In the past, I have had a stroke, pulmonary embolism, deep vein thrombosis, and/or blood clots. If yes, please explain below.
Explain how you have had issues with anesthesia. If not applicable put N/A
Explain your current use of hormone replacement therapy. If not applicable put N/A
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Explain your past use of hormone replacement therapy. If not applicable put N/A
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Explain if you have had a stroke, pulmonary embolism, deep vein thrombosis, and/or blood clots. If not applicable put N/A
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HRT Checklist for Men - Please indicate degree of symptom.
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Rows
Never
Mild
Moderate
Severe
Fatigue
Joint pain / Muscle Ache
Sleep Problems / Insomnia
Irritability
Anxiety
Depressed Mood
Lacking Vitality
Declining Mental Ability / Focus / Concentration / Brain Fog
Decreased Muscle Strength
Weight Gain / Belly Fat / Inability to Lose Weight
Migraines / Headaches
Decreased Sex Drive / Libido
Decreased Morning Erections
Decreased Ability to Perform Sexually
Infrequent or Absent Ejaculations
No Results from ED Medications
Hair Loss
Signature - Your signature signifies your consents to the use and disclosure of your PHI by our office during treatment, billing, reimbursement, and medical office operations. You agree and consent that your PHI may be communicated to you via telephone or email (encrypted or unencrypted).
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