Testosterone Patient Intake form

Please answer these questions truthfully and to the best of your knowledge. This will allow us to design a treatment plan specifically designed for you. Your honest answers are greatly appreciated. If it does not apply, write N/A.

First Name

Last Name

Date of Birth

Any family member history conditions such as prostate cancer, heart attacks, stroke, diabetes, high blood pressure

	No	Yes
Family medical History

Type the affected family member and the condition "Ex: Mother, Diabetes 2"

Patient Signature

Sign Here

	No	Yes
Prostate or breath cancer
BPH
Heart failure or HTN (uncompensated)
PSA >3.0
Myocardial infarction
Abnormal EKG

	No	Yes
Desires fertility
History of sleep apnea w/out treatment
History of Polycythemia

	No	Yes
Low libido
Decreased spontaneous erections
Breast discomfort
Gynecomastia
Testicle size reduction
Unusual sweating
Hot flashes:
Loss axillary or pubic hair

	No	Yes
Weight changes
Lack of energy
Fall sleep after dinner
Low motivation
Decreased muscle mass
Memory/concentration problems

	No	Yes
Do you have anxiety problems?
Do you feel depressed?
Do you have problems with eating or your appetite?
Do you feel unmotivated in life?
Do you have trouble sleeping?