Men’s Enclomiphene Intake Form | Clinical Evaluation

Men’s Enclomiphene Intake Form | Clinical Evaluation

This intake form helps our licensed providers review symptoms, goals, medical history, and relevant labs to determine whether treatment may be medically appropriate. Submission does not guarantee eligibility, diagnosis, or a prescription, and all care decisions are made after provider review.
Optimize by JaeNix

Address: 5301 Alpha Rd, Suite 34, Room 21, Dallas TX 75240

Treating Provider: Jessica Boggs, APRN

Medical Director: Simal Patel, MD

Phone Number: 2148906180

Booking Link: Book HERE
Full Name

First NameLast Name
Date of Birth

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Date
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Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Upload front of your driver's license

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Upload back of your driver's license

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Address

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What is Enclomiphene?
Enclomiphene is a selective estrogen receptor modulator that works by signaling the brain to increase natural testosterone production through increased LH and FSH signaling. Unlike testosterone replacement therapy, enclomiphene is often considered in men who want to preserve fertility and support their own endogenous testosterone production rather than replace it directly.
Who is Enclomiphene best for?
Enclomiphene may be a good option for men with symptoms of low testosterone, men with secondary hypogonadism, men who want to preserve fertility, younger men with borderline or low testosterone, or men who want to try a fertility-preserving approach before considering TRT.
Who may not be the best candidate?
Enclomiphene may not be the best option in men with primary testicular failure, men who do not respond appropriately to pituitary signaling, men with more complex hormone histories, or men whose clinical picture suggests TRT may be more appropriate.
I understand this is a cash pay medical programI understand a Men’s Hormone Consult is required prior to starting therapyI understand treatment decisions are based on symptoms, goals, labs, and medical historyI understand enclomiphene is not testosterone replacement and works differentlyI understand that if I need testosterone replacement therapy instead of enclomiphene, at least one in person visit in Dallas, Texas will be required before starting treatment due to Texas controlled substance prescribing lawsI understand prescriptions are never guaranteed and are issued only if medically appropriate
I understand enclomiphene works by stimulating natural testosterone productionI understand enclomiphene is not the same as testosterone replacement therapyI understand enclomiphene may not be appropriate for every patientI understand final recommendations are based on provider review
Low energy or fatigueLow libidoErectile concernsPoor motivationBrain fogDecreased strength or muscle massIncreased body fat or poor body compositionFertility preservation while improving testosteroneGeneral hormone optimizationOther
Low energyFatigueLow libidoDifficulty achieving erectionsDifficulty maintaining erectionsBrain fogReduced motivationDepressed moodIrritabilityPoor workout recoveryLoss of muscle massIncreased abdominal fatReduced strengthPoor sleepNo current symptoms
What are your goals for treatment?
Required baseline labs:
Total Testosterone, Free Testosterone, SHBG, LH, FSH, Albumin, and Estradiol. If you do not have complete labs from the last 90 days, we can order them through Quest Diagnostics. Cash pay lab option is $100.
Yes, I have complete labs and will upload themNo, I do not have recent labsI have labs, but I am not sure if they are complete
Total TestosteroneFree TestosteroneSHBGLHFSHAlbuminEstradiolI am not sure
Upload your most recent hormone labs

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Yes, I want to order Quest labsNo, I will upload or obtain my own labs first
YesNo
If yes, please describe your response, side effects, dose, and why you stopped
YesNo
YesNo
YesNoNot sure
YesNoNot sure
YesNoNot sure
High blood pressureHeart diseaseHeart attackStrokeBlood clotting disorderSleep apneaLiver diseaseKidney diseaseDiabetes or insulin resistanceProstate enlargementElevated PSAProstate cancerInfertilityDepression or anxietyNone of the above
Please list all current medications, supplements, peptides, hormones, or prescriptions you are taking
Please list any medication allergies or adverse reactions
Tadalafil may be considered as an optional add on for appropriate patients for erectile support, blood flow support, and in some cases urinary symptom support. It is not appropriate for all patients.
YesNo
YesNoNot sure
Difficulty achieving erectionsDifficulty maintaining erectionsReduced erectile qualityPerformance anxietyUrinary symptomsNone of the above
YesNoNot sure
YesNoNot sure
YesNoNot sure
I understand submission of this form does not establish a provider patient relationshipI understand submission of this form does not guarantee treatment or prescription approvalI understand all treatment decisions are made only after provider reviewI understand follow up labs and monitoring may be requiredI understand failure to complete requested follow up may affect ongoing treatment eligibility
Potential considerations with enclomiphene may include headache, mood changes, visual disturbance, elevated estradiol, or inadequate symptom response.

Potential considerations with tadalafil may include headache, flushing, nasal congestion, back pain, dizziness, or blood pressure effects.

Therapy is individualized and not all patients are candidates.
I have provided truthful and accurate information to the best of my knowledgeI understand the risks, benefits, alternatives, and limitations of evaluation and treatmentI consent to medical review by Optimize by JaeNix and its licensed providersI understand that a Men’s Hormone Consult is required before starting therapy
Patient Signature
Today’s Date

MonthDayYear
Date
YesNo
YesNo
YesNo
YesNoNot sure
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Please explain any medical conditions you checked above
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Men’s Enclomiphene Intake Form | Clinical Evaluation

What is Enclomiphene?

Who is Enclomiphene best for?

Who may not be the best candidate?

Required baseline labs: