male hormone therapy clinical note

BEAUTY SHOTS, LLC
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Weight*
Height*
What are your current symptoms? Please check all that apply:

Fatigue/low energyDecreased libidoErectile dysfunctionReduced morning erectionsDifficulty building muscleIncreased body fatDecreased motivationBrain fog/poor focusDepressionAnxietyIrritabilityPoor sleepHot flashesDecreased enduranceHair thinningGynecomastia (breast tissue enlargement)

Medical History

	Yes	No
Heart disease
Heart attack
Stroke
Hypertension
High Cholesterol
Diabetes
Sleep apnea
Blood clots
Prostate issues/cancer
Breast Cancer
Elevated PSA
BPH
Thyroid cancer
Liver disease
Kidney disease
Anxiety or depression
Prostate biopsy

Any other medical history you would like us to know about.
Current urinary symptoms:

NoneWeak streamDifficulty starting urinationFrequent UrinationNighttime urination
Do you have a family history of:

Prostate cancerHeart diseaseBlood clotsDiabetes
Do you take any medications

YesNo
If yes, please list. PLEASE INCLUDE ANY SUPPLEMENTS*
Are you allergic to anything

YesNo
If yes, please list.
Have you received testosterone therapy or hormone treatment before?

YesNo
What method have you tried?

PelletsInjectionsGels/CreamsPatchesOral Medications
Date of last hormone therapy

MonthDayYear
Date
Dose given (if known)
Do you have any children

YesNo
Are you planning to have children?

YesNo
Do you have fertility issues?

YesNot that I am aware of
If yes, please explain.
Do you have a history of testicular injury, surgery, or infection?

YesNo
If yes, please explain.
How often do you exercise?

Never1-2 times a week3-5 times a week5+ times a week
Do you smoke or vape?

YesNo
Do you drink alcohol

YesNo
How often do you drink

dailyweekly2-4 times a monthonce a month
How many drinks do you typically have when drinking?
Do you use any recreational drugs?

YesNo
If yes, please explain.
Procedure Description

Hormone therapy involves the subcutaneous insertion of biodentical hormone pellets into fatty tissue, typically in the hip or flank area. Pellets release hormones gradually over several months.

Expected Benefits

Possible benefits may include improved energy, mood, libido, sleep, mental clarity, muscle tone, bone density, and overall well-being. Results vary and are not guaranteed.

Risks and possible side effects

Risks may include but not limited to, pain, bruising, swelling, infection, scarring, pellet extrusion, acne, hair changes, mood changes, fluid retention, breast tenderness, spotting or bleeding, voice changes, increased red blood cell count, cholesterol changes, and hormone imbalance.

Alternatives

Alternatives include oral medications, topical therapy, injections, patches, or choosing no treatment

Follow-Up & Labs

Lab monitoring and follow-up appointments are required and are the patient's responsibility.

Consent

I have read and understand this information and voluntarily consent to hormone pellet therapy.

IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THIS TREATMENT, OR ANY QUESTIONSWHATSOEVER CONCERNING THIS PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK THE STAFF NOW BEFORE SIGNING THIS CONSENT FORM.

HIPAA Authorization and Acknowledgement for Open Setting Communication

As a concierge medical spa operating in a home-based setting, we strive to provide a welcoming and comfortable atmosphere. Due to the nature of our space, some discussions regarding health, wellness, and treatment goals may occur in a shared or open area where others may be present.

To comply with the health insurance portability and accountability act of 1996 (HIPAA), and to respect you right to privacy, we ask you to review and acknowledge the following:

Acknowledgement of an open setting environment

I understand that:

- Consultations or conversations regarding weight goals, health history, treatment plans, vitamin injections, prescription therapies, IV therapy, toxin , and dermal filler may take place in an open area.

- Although reasonable efforts will be made to maintain confidentiality, there is a possibility that other clients or individuals may overhear portions of these conversations.

- I am not required to have any personal health discussions in an open setting.

Client Rights

- I understand that I may change my preference at any time by informing a staff member.

- I understand that my choice will not affect my care or access to services in any way.
Please select the following:*

I authorize Beauty Shots LLC to discuss my goals, treatment, and services in an open setting where others may be present. I know that if I do not feel comfortable with this I can request to have my appointment taken in a private area.
Client Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
PROVIDER ONLY DOCUMENTATION BELOW
HISTORY OF PRESENT ILLNESS
How old is the client?
The patient is a male complaining of a hormone imbalance and looking for an evaluation and management.
He reports symptoms that have been present for approximately
He has previously attempted the following treatments or interventions
HPI NOTES
REPORTED SYMPTOMS
The patient reports fatigue, low energy, decreased libido, erectile dysfunction, mood changes, brain fog, poor sleep, decreased muscle mass, increased body fat, and reduced motivation.
REVIEW OF SYSTEMS (ROS)
Constitutional: Reports fatigue and decreased energy. Denies fever or chills. Cardiovascular: Denies chest pain, palpitations, syncope, or history of blood clots. Respiratory: Denies shortness of breath or cough. Gastrointestinal: Denies abdominal pain, nausea, vomiting, or changes in bowel habits. Genitourinary: Reports erectile dysfunction and decreased libido. Denies dysuria or hematuria. Neurologic: Reports brain fog.

Patient denies focal weakness, dizziness, or headaches. Psychiatric: Reports mood changes. Denies suicidal or homicidal ideation.
Additional ROS notes
PHYSICAL EXAMINATION
General: Well-appearing male in no acute distress. Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Respiratory: Lungs clear to auscultation bilaterally without wheezes, rales, or rhonchi. Abdomen: Soft, non-tender, non-distended, no organomegaly. Neurologic: Alert and oriented ×3, cranial nerves II–XII grossly intact. Skin: Warm, dry, intact without rash.
Physical Exam Additional Notes
ASSESSMENT / PLAN
Male patient with symptoms consistent with hypogonadism. Symptoms, medical history, and risk factors were reviewed. Patient is an appropriate candidate for hormone pellet therapy pending laboratory evaluation. Risks, benefits, alternatives, and expectations of pellet therapy were discussed in detail. Patient verbalized understanding and wishes to proceed.

Laboratory evaluation will be obtained prior to pellet placement. Based on clinical symptoms, body composition, and anticipated response, the patient is anticipated to require testosterone pellet therapy in the range of 600–1200 mg. Final dosing will be individualized after review of laboratory results and clinical response.

Pellet insertion will be scheduled following review of laboratory results and medical clearance. Post-procedure care and expectations were reviewed. Patient will receive a phone or telehealth follow-up approximately 4–6 weeks after insertion to assess symptom response and screen for adverse effects. Repeat hormone labs will be obtained approximately 6–8 weeks post-insertion or sooner if clinically indicated.
Assessment/Plan Notes
RED FLAGS & CONTRAINDICATION SCREENING
The patient denies a history of prostate cancer, breast cancer, unexplained elevated PSA, active or prior venous thromboembolism, stroke, myocardial infarction, severe liver disease, uncontrolled hypertension, or known clotting disorders.
BLACK BOX WARNINGS & RISK DISCUSSION
Potential risks of testosterone therapy were reviewed, including erythrocytosis, cardiovascular events, prostate-related risks, infertility, mood changes, and sleep apnea exacerbation. The patient verbalized understanding that therapy is elective and requires ongoing monitoring.
ICD-10 CODES
Primary: Z79.890 – Hormone Replacement Therapy Secondary: R53.83 – Other Fatigue | R68.82 – Decreased Libido | E29.1 – Testicular Hypofunction

Provider Name: Stacy Sims, FNP-C
Provider Signature*

Powered by Jotform SignClear
Date

MonthDayYear
Date
Provider name: Stacy Sims FNP-C

NPI: 149-733-0724
Should be Empty:

BEAUTY SHOTS, LLC

HISTORY OF PRESENT ILLNESS

REPORTED SYMPTOMS

REVIEW OF SYSTEMS (ROS)

PHYSICAL EXAMINATION

ASSESSMENT / PLAN

RED FLAGS & CONTRAINDICATION SCREENING

BLACK BOX WARNINGS & RISK DISCUSSION

ICD-10 CODES