Name *

First

Last

Contact Number *

Email *

Decline in your feeling of general well-being *

(general state of health, subjective feeling)

Joint pain and muscular ache *

(lower back pain, joint pain, pain in a limb, general back ache)

Excessive sweating *

(unexpected/sudden episodes of sweating, hot flushes independent of strain)

Sleep problems? *

(difficulty in falling asleep difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)

Increased need for sleep, often feeling tired *

Irritability *

(feeling aggressive, easily upset about little things, moody)

Nervousness *

(inner tension, restlessness, feeling fidgety)

Anxiety *

(feeling panicky)

Physical exhaustion / lacking vitality *

(general decrease in performance,reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, of having to force oneself to undertake activities)

Decrease in muscular strength *

(feeling of weakness)

Depressive mood *

(feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use)

Feeling that you have passed your peak *

Feeling burnt out, having hit rock-bottom *

Decrease in beard growth *

Decrease in ability/frequency to perform sexually *

Decrease in the number of morning erections *

Decrease in sexual desire/libido *

(lacking pleasure in sex, lacking desire for sexual intercourse)

Do you have cold hands and feet? *

Do you have daily bowel movements? *

Do you have gas, bloating or abdominal pain after eating? *

Please select your WEEKLY Activity Level based on this criteria? *

Physical activity that accelerates heart rate / Breathlessness

Please share any additional comments about your symptoms you would like to address.

Please list any prior hormone therapy?

Recent PSA?

Recent Digital Rectal Exam (Date):

Recent Digital Rectal Exam Results?

History of Prostate problems or Biopsy. If so, please provide details.

Fee Acknowledgement *

Yes

Although more insurance companies are reimbursing patients for Bio-Identical Hormone Replacement Therapy, there is no guarantee. You will be responsible for payment in full at the time of your BHRT procedure (see fee schedule below). New Patient Consultation Fee (free for members) $150. Male Hormone Pellet Insertion Fee: $650. Male Hormone Pellet Insertion Fee (> 2000mg) $750

Chart ID

Office Use Only

DOB

Office Use Only

APP Date?

Office Use Only

HRT Male Checklist

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