Past Medical History- Male HRT

Full Name*

First NameLast Name
DOB*

MonthDayYear
Date
Date*

MonthDayYear
Date
In the past 2 weeks, please indicate if you have had any of these symptoms, and rate the symptom from 1 to 5.

1 - Not too much of a problem, 5 - Very much a problem. Please use the comment area below to explain further or comment.

Rows	1	2	3	4	5	N/A
Acne or Oily Skin
Decreased Morning Erections
Decreased Quality of Erections
Erectile Dysfunction
Low Libido
Lack of Motivation
Sleep disturbance/insomnia
Fatigue
Muscle gain/loss
Depression Symptoms
Swelling in hands/feet
Brain fog or Memory loss
Decreased concentration
Night sweats/hot flashes
Anxiety/irritability
Mood Swings
Tearful
Craving Sweets or Salt
Constipation or Diarrhea
Poor recovery after workouts
Difficulty losing weight
Hair loss

Rows	0	1	2	3	4
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision (does not include far sightedness)

Rows	0	1	2	3	4
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores

Rows	0	1	2	3	4
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain

Rows	0	1	2	3	4
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness

Rows	0	1	2	3	4
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities

Rows	0	1	2	3	4
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressive
Depression

Rows	0	1	2	3	4
Frequent Illness
Frequent or urgent urination
Genital itch or discharge

Complaints and Concerns