• IMHS Testosterone Replacement Therapy Patient Intake

    Innovative Men’s Health | Bellevue, WA | (425) 455-1700 | innovativehealthsolutions.net — Please complete this intake so our clinical team can understand your symptoms, medical history, medications, and treatment goals. A licensed provider will review your information to determine whether testosterone therapy may be appropriate. Submission does not guarantee treatment or a prescription. We’ll contact you about required labs, consultation, and next steps.

  • Patient Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Biological Sex*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Contact Method

  • Emergency Contact

  • Format: (000) 000-0000.

  • Referral and Goals

  • What are you seeking care for?*

  • Current and Past Medical History

  • Please select any current or past medical conditions that apply*

  • Allergies

  • Medication allergies

  • Current Medications and Supplements

  • Prior Hormone/Anabolic/Performance Use

  • History of prior hormone or performance-enhancing use*
  • Do you desire to father children within the next 1–2 years? TRT can suppress sperm production.*

  • ADAM Questionnaire

  • Has your libido decreased?*
  • Do you have a lack of energy?*
  • Has your strength or endurance decreased?*
  • Have you lost height?*
  • Have you noticed a decreased enjoyment of life?*
  • Do you often feel sad or grumpy?*
  • Are your erections less strong?*
  • Have you noticed a deterioration in your sports ability?*
  • Do you often fall asleep after dinner?*
  • Have you noticed a deterioration in your work performance?*

  • Symptom Severity

  •

  • Lifestyle and Body Metrics

  •
  • Snoring or Stopped Breathing During Sleep?
  • Tobacco / Nicotine / Vape Status
  • Cannabis Use

  • Family History

  • Family history conditions*

  • Recent Labs

  • Were testosterone or hormone labs completed in the last 12 months?*
  • Date of most recent labs
     - -
    2 digit month, 2 digit day, 4 digit year
  • Please complete this intake so our clinical team can understand your symptoms, medical history, medications, and treatment goals. A licensed provider will review your information to determine whether testosterone therapy may be appropriate. Submission does not guarantee treatment or a prescription. We’ll contact you about required labs, consultation, and next steps.

  • Other Providers and Pharmacy

  • Acknowledgments and Consents

  • Patient Attestation

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: