Biote Male Health Assessment, History and Symptoms
For CDSS Round 1
Patient Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Today's Date
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-
Month
-
Day
Year
Date
Date of Birth
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Month
-
Day
Year
Date
Age
*
Weight (in pounds)
*
Height
*
Health Assessment
Please mark the appropriate box for each symptom you may be experiencing.
Symptoms
Rows
None
Mild
Moderate
Severe
Very Severe
Physical Exhaustion (fatigue, lack of energy, stamina or motivation)
Sleep Problems (difficulty falling asleep or sleeping through the night)
Irritability (mood swings, feeling aggressive, angers easily)
Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous)
Decline in drive or interest (loss of "zest for life," feeling down or sad)
Joint and muscular symptoms (poor recovery after workout, inability to add muscle, joint pain, muscle weakness)
Difficulties with memory (concentration, finding the right word, or retaining information)
Sexual Desire or Performance (reduced or diminished)
Erectile changes (weaker erections, loss of morning erections)
Ejaculations (infrequent or absent)
Sweating (night sweats or increased episodes of sweating)
Hair loss, rapid or thinning
Feeling cold all the time, having cold hands or feet
Headaches or migraines (increase in frequency or intensity)
Weight (difficulty losing weight despite diet/exercise)
Bladder problems (difficulty in urinating, increased need to urinate)
Other symptoms or unique health circumstances to take into consideration:
Patient Questions
Rows
Yes
No
Currently trying to conceive?
Are you on a 5-alpha reductase inhibitor?
Are you on a PDE-5 Inhibitor (Cialis, Viagra, Etc.)
Are you on any other testosterone boosting medication (Clomid, HCG, etc.)?
Are you currently taking BHRT or HRT? (If yes, see below)
Are you currently on statins?
Are you a smoker?
Are you currently on oral nitrates?
If yes to BHRT or HRT, select type of Hormones:
Testosterone
Thyroid
List name and dose of hormone(s):
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Medical History
Select ALL that Apply
Fertility:
Want to Maintain Fertility
Cardiovascular Conditions:
Heart Attack or Stroke (within last 6 months)
Tachycardia
DVT or Blood Clot (within last 6 months)
Hypertension
Hyperlipidemia
Obstructive Sleep Apnea
Patient Takes Anticoagulant Medication
Atrial Fibrillation
Cancer
Breast Cancer or History of Breast Cancer
Active Prostate Cancer or History of Prostate Cancer
Thyroid Cancer or History of Thyroid Cancer
Except for Basal Cell Carcinoma, Any Other Cancers?
Other
Endocrine and Metabolic:
Diabetes Type 2 or Insulin Resistance
Hyperthyroid
Hypothyroid
Multiple Endocrine Neoplasia Type-2
Autoimmune Conditions:
Diabetes Type 1
Hashimoto's Thyroiditis
Graves' Disease
Rheumatoid Arthritis
Multiple Sclerosis
Systemic Lupus (Erthematosus)
IBS (Irritable Bowel Syndrome)
Crohn's Disease
Ulcerative Colitis
Organ Specific Conditions
Liver Disease or History of Liver Disease
Kidney Disease or History of Kidney Disease
LAM (Lymphangioleiomyomatosis)
Osteoporosis or Osteopenia
Prostate Enlargement (BPH)
HIV
Hepatitis
Hemochromatosis
Pancreatitis or History of Pancreatitis
History of Gall Bladder Disease
Polycythemia Vera (PV)
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Next
Symptoms and Concerns
Select ALL that Apply
Acne
Erectile Dysfunction (ED)
Decreased Libido
Decreased Desire
Inability To or Delayed Orgasm
Weight Gain
Decreased Muscle Mass
Difficulty Sleeping
Urinary Incontinence
Dry or Flaking Skin
Lack of Energy (Fatigue)
Decrease in Strength or Endurance
Decrease in Work Performance
Frequent Urinary Tract Infection
Brittle Nails
Thinning Eyebrows
Hair Thinning
Cold Hands or Feet
Mind Racing at Bedtime
Eating When Stressed
Mood Swings
Gynecomastia
Abdominal Obesity
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