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TRT - Testosterone Replacement Therapy
1
How Stealth Health Works
A short message from our CMO
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2
Email
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example@example.com
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3
Medication
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4
Dosage Instructions
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5
Quantity
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6
Repeats
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7
Please enter a promo code if you have one (Optional)
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8
Have you used testosterone replacement therapy in the past?
YES
NO
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9
If yes, please specify what therapy you were on and for how long:
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10
Do you have a decrease in libido (sex drive)?
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11
Do you have a lack of energy?
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12
Do you have a decrease in strength and/or endurance?
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13
Have you lost height?
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14
Have you noticed a decreased “enjoyment of life?”
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15
Are you sad and/or grumpy?
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16
Are your erections less strong?
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17
Have you noticed a recent deterioration in your ability to play sports?
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18
Are you falling asleep after dinner?
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19
Has there been a recent deterioration in your work performance?
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NO
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20
Do you have a history of any of the following?
Suspected/diagnosed prostate carcinoma or hyperplasia
Suspected/diagnosed breast carcinoma
Soy allergy
History of cancer or metastases
Hypertension
Cardiac, Renal, or Hepatic disease
Myocardial Infarction (Heart Attack)
Stroke
Diabetes
Sleep apnea
Hemochromatosis
Hypercalcemia
Depression
Thyroid or adrenal dysfunction/disorder
Visual disturbances
Hyperlipidemia
None
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21
Have you been diagnosed with a hormonal imbalance?
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NO
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22
If yes, please specify:
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23
Have you had a blood test in the past year?
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NO
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24
Do you have your previous results?
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NO
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25
Please upload your previous blood results here
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Select files to upload
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26
Was anything abnormal with the blood test? If yes, please specify:
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27
Are you and your partner planning to conceive soon?
YES
NO
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28
Are you on any of the following medications?
Insulin
Propranolol
Corticosteroids
Anti-coagulants
St. John’s wort
Fluoroestradiol F18
Ospemifene
None
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29
Do you have any mental health diagnoses?
YES
NO
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30
If yes, please specify:
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31
How often do you consume alcohol?
Rarely/Never
Sometimes
Frequently
Daily/Always
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32
Have you used any of the following substances in the past six months?
Cocaine
Methamphetamine
Opioids
Cannabis
None
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33
Do you smoke?
YES
NO
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34
How often do you smoke? (Packs a week, etc.)
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35
Are you using any nicotine replacement products to aid in quitting smoking?
YES
NO
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36
Please specify:
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37
Do you have any concerns about potential side effects of testosterone treatments?
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38
Is there anything else you would like to share with the healthcare team?
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39
Full Name
*
This field is required.
First Name
Last Name
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40
Phone Number
*
This field is required.
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41
Date of Birth
Year, Month, Day
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42
OHIP?
YES
NO
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43
Please enter here:
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44
Biological Sex
Male
Female
Intersex
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45
Are you currently pregnant or breast feeding?
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NO
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46
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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47
Allergies?
YES
NO
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48
What is your allergy?
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49
Are you currently taking any medications, vitamins, herbs, or supplements?
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50
Please list your medications, vitamins, herbs, and supplements here:
(Name, Strength, Regimen)
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51
Do you have any medical conditions?
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52
Please list your medical conditions here:
(Name, How long you've had the condition)
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53
Please take a photo of your ID
*
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I.e Health card, Drivers license,etc
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54
Please enter your ID number
*
This field is required.
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55
Signature
By signing below you accept that the above information provided is accurate and truthful. You also acknowledge that a staff member will contact you for ID verification prior to dispensing the prescription.
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