TRT - Testosterone Replacement Therapy

1

Have you used testosterone replacement therapy in the past?* This field is required.

YESNO

2

If yes, please specify what therapy you were on and for how long:

3

Do you have a decrease in libido (sex drive)? * This field is required.

YESNO

4

Do you have a lack of energy? * This field is required.

YESNO

5

Do you have a decrease in strength and/or endurance? * This field is required.

YESNO

6

Have you lost height? * This field is required.

YESNO

7

Have you noticed a decreased “enjoyment of life?” * This field is required.

YESNO

8

Are you sad and/or grumpy? * This field is required.

YESNO

9

Are your erections less strong? * This field is required.

YESNO

10

Has there been a recent deterioration in your work performance? * This field is required.

YESNO

12

Have you been diagnosed with a hormonal imbalance?* This field is required.

YESNO

13

If yes, please specify:

14

Have you had a blood test in the past year?* This field is required.

YESNO

15

Do you have your previous results?

YESNO

16

Please upload your previous blood results here

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

17

Was anything abnormal with the blood test? If yes, please specify:

18

Are you and your partner planning to conceive soon?* This field is required.

YESNO

20

Do you have any mental health diagnoses?* This field is required.

YESNO

21

If yes, please specify:

22

How often do you consume alcohol?* This field is required.

Rarely/Never

Sometimes

Frequently

Daily/Always

23

Have you used any of the following substances in the past six months?* This field is required.

Cocaine

Methamphetamine

Opioids

Cannabis

None

24

Do you smoke?* This field is required.

YESNO

25

How often do you smoke? (Packs a week, etc.)

26

Are you using any nicotine replacement products to aid in quitting smoking?* This field is required.

YESNO

27

Please specify:

28

Do you have any concerns about potential side effects of testosterone treatments?

29

Is there anything else you would like to share with the healthcare team?

30

Terms and Conditions* This field is required.

31

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