BioTE Intake Form - Male Patient

BioTE Intake Form - Male Patient

Bioidentical Hormone Questionnaire & History
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Now

MonthDayYear
Date
Calculated Current Age (office use)
Medical Services Plan BC Care Card Number
Weight: current weight* . Height: height*
Occupation: Occupation
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family physician's name:Doctor's name . Phone: Area Code Phone Number . Address:Doctor's Address (if known)
Marital Status
Do you use any of the following (please check):Cigarettes Vape e-cigarettes Cigars None of the above Other
Please list any prescription medication you are taking, with doses if known:
Please list any supplements / vitamins you are taking, with doses if known:
As testosterone therapy may affect fertility (usually short term), please answer the following questions about children.
Do you have any biological children?     .
Are you considering having children in the future?  (select all that apply)Yes   Yes.   No, I do NOT wish to have children in the future.   Unsure.
If you have not had children, have you had a prior semen analysis?

Family Medical History. Please indicate if you have any family history of:*

Medical History. Please indicate if you have a history of any of the following:*

	Yes	No	Unsure
High blood pressure / hypertension
High cholesterol
Diabetes or impaired glucose tolerance
Thyroid Disease
Stroke or heart attack
Atrial fibrillation or other arrhythmia
Blood clot or pulmonary embolus
COVID-19
Other lung disease
Snoring or sleep apnea
Anemia
Hemochromatosis
Multiple blood donations
Liver disease (hepatitis, fatty liver, cirrhosis)
HIV
Hepatitis B or C
Kidney disease
Arthritis
Osteoporosis
Autoimmune disease
Alopecia or other hair loss
Prostate enlargement (BPH)
Difficulty Urinating
Prostate cancer
Other cancer
Depression/anxiety
Vasectomy
Erectile dysfunction

If you answered "yes" to any of the above, please explain:
Is there anything else about your health or other circumstances that is important for us to know?
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