Medical • Chiropractic • Physical Therapy • Functional Enhancement

Home
Facebook
Videos
Coupon

Services
We Treat
Weight Loss
BHRT Therapy
PRP Therapy
Therapeutic Peptides

Meet our Team

Give us a Call

Arlington 703-535-8887 Purcellville 540-441-7433

Ask the Doctor

Make an Appointment

book or request online

Hormone Replacement Therapy Forms for Men

This form is loading. If it does not appear in a few seconds, please call our office at 703-535-8887 (Arlington) or 540-441-7433 (Purcellville) to complete it.

Hormone Replacement Therapy Questionnaire

Enter Your Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Phone #

Age

Occupation

Marital Status

Married

Divorced

Widow

Living with Partner

Single

Emergency Contact

Health and Background Information

Primary Care Physican

Current Symtoms

Fatigue

Joint Pain/Muscle Ache

Muscle Loss or Decreased Strength

Low Libido

Erectile Dysfunction

Sleep Problems

Weight Gain/Belly Fat/Inability ro Lose Weight

Hair Loss

Mood Changes (irritability, anxiety, depression)

Other Symptions

Medical History

Diabetes

Hypertension

Heart Disease

High Cholesterol

Stroke/Heart Attack

Blood Clot and/or Pulmonary Emboli

Hemochromatosis

Any form of Hepatitis or HIV

Thyroid Disorder

Cancer

Elevated PSA or Prostate Enlargement

Chronic Liver Disease

Sleep Apnea

Arthritis

If any checked above, provide details below and/or add anything not listed above:

Surgical History

Current Medications & Suppliments

Smoking Status

List any Allergies/Intolerances

Family History List chronic illnesses for family members listed below (examples: high blood pressure, high cholesterol, diabetes, cancer, bleeding disorders, autoimmune diseases, etc.)

Surgical Layout Other

Mother:

Father:

Siblings:

Grandmother:

Grandfather:

How would you rate the stress in your life, 10 being the highest?

How do you cope with stress?

Goals for HRT?

Symptom Relief

Energy Levels

Sexual Health

Bone Health

Mood Stabilization

Other Goal(s):

Have you tried HRT (Testosterine) in the past?

Yes

If Yes to Testosterone Therapy, Method Used:

Oral

Patch

Cream/Gel

Injection

Pellet

Duration of Use (if applicable):

Reason for Stopping (if applicable):

Previously had an allergic reaction to hormones or pellets?

Any other questions or items you would like to discuss?

Questionnaire About Symptoms of Low Testosterone

You have decrease in libido

Never (0)

Average (1)

Poor (2)

Terrible (3)

You have a lack of energy

Never (0)

Average (1)

Poor (2)

Terrible (3)

You have a decrease in strength and/or endurance

Never (0)

Average (1)

Poor (2)

Terrible (3)

You are sad and/or grumpy

Never (0)

Average (1)

Poor (2)

Terrible (3)

You lost height

Never (0)

1-1.4 inches (1)

1.5-1.9 inches (2)

2 inches or more (3)

You noticed a decreased "enjoyment of life"

Never (0)

Average (1)

Poor (2)

Terrible (3)

Your erections less strong

Never (0)

Average (1)

Poor (2)

Terrible (3)

You noticed a recent deterioration in your ability to play sports

Never (0)

Average (1)

Poor (2)

Terrible (3)

You fall asleep after dinner

Never (0)

Average (1)

Poor (2)

Terrible (3)

There's been a recent deterioration in your work

Never (0)

Average (1)

Poor (2)

Terrible (3)

You have memory loss, decreased ability to concentrate

Never (0)

Average (1)

Poor (2)

Terrible (3)

You have backache, joint pain, stiffness

Never (0)

Average (1)

Poor (2)

Terrible (3)

Less than 6 points - it is not likely that you have hormone deficiency 7-16 points - mild hormone deficiency 17-26 points - moderate hormone deficiency Above 27 points - severe hormone deficiency

Consent & Acknowledgement

I understand that hormone replacement therapy has potential risks and benefits.

I confirm that the information provided is accurate.

Signature of Patient / Responsible Person (type your name)

Date