TRT Monthly Check In & Refill Request
Name
First Name
Last Name
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Are you currently taking your testosterone as prescribed?
Please Select
Yes
No
If no: please explain
What is your current testosterone dose and frequency?
How are you feeling on your current TRT regimen?
Doing well / symptoms improved
Some improvement
No significant improvement
Symptoms have worsened
Are you experiencing any side effects from your current TRT regimen?
Acne/oily skin
Increased irritability or mood changes
Breast tenderness or enlargement
Swelling/fluid retention
Increased blood pressure
Heart palpitations
Shortness of breath
Decreased testicular size
Hair loss/thining
None of the above
Other
If you selected "other" please describe the side effect(s) you are experiencing.
If medically appropriate, would you be interested in increasing your testosterone dose?
Please Select
Yes
No
Unsure / Provider recommendation
Submit
Should be Empty: