Male Health Questionnaire

Bio-Identical Hormone Replacement Therapy

We’re so glad you found us on the internet and we would love the opportunity to help you feel like the man you know you can be! The answer is Testosterone Replacement and we’re here to help you feel your best...we are just a phone call away. We recommend that you fill out our Male Health Questionnaire so that we can better assist you. You can also come into our office or call to have a Free Consultation with our Male Pharmacist or Registered Nurse. You took the first step… now let us do the rest!

First Name*
Last Name*
Date of Birth

Do you drink alcohol?
If yes, how much?
Do you smoke?
If yes, how much?
Please list all Medications, Hormones & Supplements
Medication Allergies
Food Allergies
Who referred you to us?
Please list your health care provider
Date of Last Visit/Checkup



Section I

Check All That Apply
Adult MumpsProstate Operation or InflammationVasectomyOrchitis or Other Testicular ProblemsPersistent Urinary Infections

Section II

Check Box That Best Describes Your Symptoms
Fatigue, tiredness or loss of energyDepression, low or negative moodIrritability, anger, or bad temperAnxiety or nervousnessLoss of memory or concentrationRelationship problem with partnerLoss of sex drive or LibidoErection or potency problemsDry skin on face or handsExcessive sweating, day or nightBackache, stiffness, joint or muscle painFrequent use of alcohol, past or presentLoss of physical staminaFeeling over-stressedLoss of early morning erectionIncreased fat distribution in chest area or hipsFeeling burned out, loss of motivationDecrease in muscle massIncrease in waist size – weight gain, especially in mid section
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