Male Hormone Optimization Form

Male Hormone Optimization Form

Whether you’re exploring hormone therapy, preparing for your first appointment, or checking in for a follow-up, this form helps us personalize your care.
Reason for Completing This Form*

I’m interested in learning more (no appointment yet)I’m preparing for my first hormone therapy appointmentI’m an established patient completing this form for a follow-up visit
Patient Information
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Current Weight (lbs)*
Height*
Current Symptom Severity Rating (Past 2 Weeks)

Please rate how much each symptom has affected you over the past two weeks. Scale: 1 = Not a Problem at All; 2 = Mild Problem; 3 = Moderate Problem; 4 = Significant Problem; 5 = Worst It’s Ever Been

I experience joint or muscle pain.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I sweat excessively or suddenly (not due to exercise).*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I have trouble falling or staying asleep.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I feel tired or low on energy.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I feel down or depressed.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I feel irritable or easily agitated.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I feel anxious or on edge.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I feel physically exhausted.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I feel weaker or notice reduced muscle strength.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I feel like I’ve passed my physical or mental peak.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I feel burnt out or like I’ve “hit a wall.”*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I notice slower or reduced beard growth.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I have difficulty with sexual performance.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I have fewer morning erections.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

I have less interest in sex or a lower libido.*

	1	2	3	4	5

1 is Not a Problem at All, 5 is Extremely Severe

General Health Questions

Please answer the following questions about your overall health and lifestyle.

How would you rate your overall health right now?*

	1	2	3	4	5

1 is Excellent, 5 is Extremely Poor

Do you often have cold hands or feet?*

YesNo
Do you have a bowel movement every day?**

YesNo
Do you experience gas, bloating, or abdominal discomfort after eating?**

YesNo
How often do you engage in physical activity that increases your heart rate or causes breathlessness?*

0-1 day per week2-3 days per weekMore than 3 days per week
Are you currently taking ADD/ADHD medications (e.g., Adderall, Concerta, Vyvanse)?*

YesNo
Do you experience chronic pain (ongoing pain lasting more than 3 months)?*

YesNo
Hormone and Prostate History
Have you ever used hormone therapy (testosterone, pellets, injections, creams, etc.)?*

YesNo
If yes, please list the type(s) and approximate dates
Have you had any prostate-related concerns or procedures (e.g., enlarged prostate, biopsy, abnormal exam)?*

YesNo
If yes, please describe:
Have you had hormone-related lab work in the past 6 months?

YesNo
Optional - Upload your most recent labs (PDF or photo)

Browse Files

Cancelof
Additional Comments or Notes About Your Symptoms:
Should be Empty:

Male Hormone Optimization Form

Patient Information

Current Symptom Severity Rating (Past 2 Weeks)

General Health Questions

Hormone and Prostate History