Past Medical History- Male HRT

Full Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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

Complaints and Concerns
What do you hope to achieve with us?
Date of symptom or injury onset?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If you had a magic wand and could erase three problems, what would they be?
Current Height
Current Weight

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