Men's HRT

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MEN'S Questionnaire
This form is an abbreviated symptom profile.

To expedite dose recommendations, please fax to (888-454-9135) your medication profile, history and physical.

Please notate in the fax the reason you are faxing information. We want to make sure it is associated with your form.
Name

First NameLast Name
Date Submitted

MonthDayYear
Date
Date of Birth

MonthDayYear
Phone Number

Area CodePhone Number
Email
example@example.com
Preferred method of contact*

PhoneEmail
PHYSICIAN / PRESCRIBER
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prescriber Name
MEDICAL & SOCIAL HISTORY
Medical History - Select all that apply

HIgh Blood PressureAlcohol UseHigh CholesterolErectile DysfunctionCardiovascular DiseaseInsomniaDiabetes MellitusMalnutritionOsteoporosisDepressionBenign Prostate HyperplasiaCancerTobacco UseAsthma / COPDOther
If you selected Cancer, what type?
Other medical condition(s)
Medications
Medication History
List all prescription and non-prescription medications you are currently taking. (Including vitamins, herbals, and supplements). Record "None" if applicable.
Drug Allergies
List all drug allergies (Including vitamins, herbals, and supplements). Record "None" if applicable.
SYMPTOMS
SELECT A BOX FOR EACH SYMPTOM that best describes how you have been feeling for the past few months.
- None - symptom not present
- Mild - present but not distressing
- Moderate - distressing, but not interfering with daily life
- Severe - very distressing, interferes with daily life
IT IS ENCOURAGED FOR THE PATIENT TO KEEP A COPY OF THIS BASELINE SYMPTOM PROFILE TO BETTER MONITOR THE PROGRESS OF THE THERAPY.
More fatigued and/or tired than usual

NoneMildModerateSevere
Decrease in muscle mass

NoneMildModerateSevere
Loss in muscle strength

NoneMildModerateSevere
Increase in waist size

NoneMildModerateSevere
Trouble losing weight

NoneMildModerateSevere
Experienced a loss in height

NoneMildModerateSevere
Decrease in sex drive

NoneMildModerateSevere
Difficulty in establishing and/or maintaining full erections

NoneMildModerateSevere
Decrease in spontaneous early morning erections

NoneMildModerateSevere
Changes in usual sleep pattern

NoneMildModerateSevere
Decrease in mental sharpness

NoneMildModerateSevere
Trouble concentrating

NoneMildModerateSevere
Experience less enjoyment in personal interests and hobbies

NoneMildModerateSevere
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MEN'S Questionnaire

PHYSICIAN / PRESCRIBER

MEDICAL & SOCIAL HISTORY

SYMPTOMS