Patient Information

First Name

Last Name

Date of Birth: MM/DD/YYYY

Email

Contact Information

Pharmacy Name (required)

Pharmacy Address (required)

Medication Name (required)

Medication Dosage (required)

1. Have you visited with your PCP or Specialist since starting the program? 1. Have you visited with your PCP or Specialist since starting the program? Yes No

1.1 If so, when and what was the outcome of your visit with them? Please be as specific as you can.

1.2. Is blood work performed? 1.2. Is blood work performed? Yes No

1.3. Please send the test results of the performed blood work.

2. What is today's height and weight (feet & lbs)?

3. Have you noticed a increase of muscle mass, strength or endurance? 3. Have you noticed a increase of muscle mass, strength or endurance? Yes No

4. Do you have an increased sex drive? 4. Do you have an increased sex drive? Yes No

5. Do you feel more energetic than prior to starting HRT? 5. Do you feel more energetic than prior to starting HRT? Yes No

6. Do you find yourself having less difficulty concentrating or focusing? 6. Do you find yourself having less difficulty concentrating or focusing? Yes No

7. How many hours of sleep do you get each night?

8. If you currently exercise, describe what you are doing, (type, time per session, frequency per week)

9. What have been your greatest difficulties in hormone replacement therapy?

10. Are you happy with your current testosterone replacement therapy protocol? 10. Are you happy with your current testosterone replacement therapy protocol? Yes No