Men's Health Colorado Onboarding

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

3

I agree to receive SMS messages from Cost Plus TRT* This field is required.By providing your phone number, you agree to receive SMS messages from Cost Plus TRT regarding appointments, follow-ups, and promotional offers. Message & data rates may apply. Message frequency varies. Reply STOP to opt out or HELP for help. Your information will not be sold or shared with third parties.”

4

Email* This field is required.

example@example.com

5

Which state do you live in?* This field is required.

6

Have you previously been diagnosed with low testosterone (via blood test)?* This field is required.If you are transferring care to us, we can use your latest labs.

YESNO

7

Are you currently on TRT?* This field is required.

YESNO

8

Do you have blood results from the last 90 days?* This field is required.If you are transferring care to us, we can use your latest labs.

YESNO

9

Have you ever been diagnosed with Prostate Cancer?* This field is required.If you are transferring care to us, we can use your latest labs.

YESNO

10

Certification on Truth* This field is required.I confirm that all answers I have given are true to my knowledge and will not hold responsible provider or provider group for issues pertained to TRT due to withholding information above.

Clear

11

First, we need to find your current BMI. You will need this calculation on the next screen.

12

What is your current BMI?* This field is required.What did the previous calculator provide you?

Over 40

30-40

25-30

Under 25 (-1)

13

Do you currently have any of the following medical conditions?* This field is required.Select all that apply

Type 2 Diabetes

High blood pressure

High cholesterol

Sleep apnea

None

14

Select any that apply to you* This field is required.Select all that apply

Personal or family history of medullary thyroid cancer

MEN2 (Multiple Endocrine Neoplasia type 2)

Severe gastroparesis

History of pancreatitis

None of the above

15

Have you tried other weight loss methods (diet, exercise, etc.)?* This field is required.

YESNO

16

Are you currently taking any weight loss medications?* This field is required.This includes prescribed medications.

YESNO

17

Certification on Truth* This field is required.I confirm that all answers I have given are true to my knowledge and will not hold responsible provider or provider group for issues pertained to TRT due to withholding information above.

Clear

18

I Am aware of the potential side effects, including:* This field is required. Common Side Effects (usually mild and temporary): Nausea Constipation Diarrhea Loss of appetite Bloating or gas Mild fatigue Burping or acid reflux Rare but Serious Side Effects These are uncommon but should be discussed with a provider immediately: Pancreatitis (severe abdominal pain, nausea, vomiting) Gallbladder issues (pain under right ribs, yellowing of skin or eyes) Kidney problems (if severe dehydration occurs) Hypoglycemia (low blood sugar – especially if taken with other diabetes meds)

Clear

19

GLP1 Calculation

20

Which of the following are you looking to improve?* This field is required.Select All That Apply

Sleep

Recovery

Libido

Mental Focus

Lower Body Fat

21

Are you currently on any peptide therapy?* This field is required.

YESNO

22

Are you open to injectable or dissolvable medications (troches/sprays)?* This field is required.

Injectable

Dissolvable

Both

Neither

23

Peptide Score

24

Do you have difficulty getting or maintaining an erection?* This field is required.

YESNO

25

Have you noticed a decline in your sexual desire?* This field is required.

YESNO

26

Are any of these medical conditions true?* This field is required.

Current nitrate use (nitroglycerin)

Severe uncontrolled heart disease

Severe, uncontrolled high blood pressure

None of the above

27

Have you tried ED medications before?* This field is required.

Yes, currently

Yes, with no result

No

28

ED Medication Acknowledgment* This field is required.I understand that ED medications (such as sildenafil or tadalafil) may cause side effects, including headache, flushing, indigestion, nasal congestion, dizziness, or vision changes. Rare but serious risks include chest pain, sudden hearing or vision loss, and erections lasting longer than 4 hours, which require immediate medical care. I also understand that these medications are not safe if I take nitrates for chest pain or have severe uncontrolled heart disease or blood pressure problems.

Clear

29

Truth & Safety Acknowledgment* This field is required.I confirm that the information I have provided is true and accurate to the best of my knowledge. I understand that false or incomplete answers may impact my ability to safely receive treatment.

Clear

30

ED Med Calculation