Please enable JavaScript in your browser to complete this form.Name *FirstLastContact Number *Email *Decline in your feeling of general well-being *NoneNoneMildModerateSevereExtremely Severe(general state of health, subjective feeling)Joint pain and muscular ache *NoneNoneMildModerateSevereExtremely Severe(lower back pain, joint pain, pain in a limb, general back ache)Excessive sweating *NoneNoneMildModerateSevereExtremely Severe(unexpected/sudden episodes of sweating, hot flushes independent of strain)Sleep problems? *NoneNoneMildModerateSevereExtremely Severe(difficulty in falling asleep difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)Increased need for sleep, often feeling tired *NoneNoneMildModerateSevereExtremely SevereIrritability *NoneNoneMildModerateSevereExtremely Severe(feeling aggressive, easily upset about little things, moody)Nervousness *NoneNoneMildModerateSevereExtremely Severe(inner tension, restlessness, feeling fidgety)Anxiety *NoneNoneMildModerateSevereExtremely Severe(feeling panicky)Physical exhaustion / lacking vitality *NoneNoneMildModerateSevereExtremely Severe(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 *NoneNoneMildModerateSevereExtremely Severe(feeling of weakness)Depressive mood *NoneNoneMildModerateSevereExtremely Severe(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 *NoneNoneMildModerateSevereExtremely SevereFeeling burnt out, having hit rock-bottom *NoneNoneMildModerateSevereExtremely SevereDecrease in beard growth *NoneNoneMildModerateSevereExtremely SevereDecrease in ability/frequency to perform sexually *NoneNoneMildModerateSevereExtremely SevereDecrease in the number of morning erections *NoneNoneMildModerateSevereExtremely SevereDecrease in sexual desire/libido *NoneNoneMildModerateSevereExtremely Severe(lacking pleasure in sex, lacking desire for sexual intercourse)Do you have cold hands and feet? *YesYesNoDo you have daily bowel movements? *YesYesNoDo you have gas, bloating or abdominal pain after eating? *YesYesNoPlease select your WEEKLY Activity Level based on this criteria? *0-1 day per week (Low)0-1 day per week (Low)2-3 days per week (Average)More than 3 days per week (High)Physical activity that accelerates heart rate / BreathlessnessPlease 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?AbnormalAbnormalNormalHistory of Prostate problems or Biopsy. If so, please provide details.Fee Acknowledgement *YesAlthough 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) $750Chart IDOffice Use OnlyDOBOffice Use OnlyAPP Date?Office Use OnlySubmit & Book Appointment