Snapshot Example TRT Questionnaire

1

What is your name?* This field is required.Please be accurate for patient records

First Name

Last Name

2

What is your email?* This field is required.This is important for appointment updates!

example@example.com

3

Phone Number* This field is required.Please make sure this is correct as we will be sending text reminders for your visits.

4

1. Do you have cancer currently?* This field is required.

YESNO

5

2. Do you have a family history of cancer?

YESNO

6

3. Are you over the age of 25?* This field is required.

YESNO

7

4. Do you have cardiomyopathy or any diagnosis of congestive heart failure?* This field is required.REQUIRED

YESNO

8

5. Have you ever taken testosterone or testosterone derivatives in the past?* This field is required.REQUIRED

YESNO

12

9. We do not accept insurance, are you okay with paying out of pocket?* This field is required.

YESNO

13

Thank you for completing the questionnaire. Unfortunately, based on your responses, you do not qualify for TRT at this time. If you have any questions, please contact us at (330) 662-1030 or email us at ohiomenshealth@gmail.com.

I made a mistake, take me back!

I will try again when my situation changes.