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Full Name *

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Age *

Sex *

What are your Hormone Goals? Type in details below *

What specific symptoms are you experiencing that make you consider TRT? *

Current Symptoms

Have you had your testosterone levels tested? If so, what were the results, and were they confirmed by multiple tests? *

Testosterone Levels

Do you have any history of prostate cancer, breast cancer, cardiovascular disease, or other significant health conditions? *

Medical History

Have you had a recent prostate exam, and what were the results? *

Prostate Health

Have you ever been diagnosed with an enlarged prostate or prostate cancer? *

Do you have a history of heart disease, high blood pressure, or high cholesterol? *

Cardiovascular Risk

Have you experienced any cardiovascular events like a heart attack or stroke? *

Do you have sleep apnea or other sleep disorders? *

Sleep Patterns

Have you had a sleep study or been evaluated for sleep apnea? *

Are you planning to have children in the future? *

Fertility Considerations

Do you have any concerns about how TRT might impact your fertility? *

How would you describe your diet, exercise routine, smoking habits, and alcohol consumption? *

Lifestyle Factors

Is there a family history of prostate cancer, breast cancer, cardiovascular disease, or other hormone-related conditions? *

Family History

Have you experienced depression, anxiety, or other mood disorders? *

Mental Health

Are you currently undergoing any treatment for mental health issues? *

Have you had any fractures or been diagnosed with osteoporosis or low bone density? *

Bone Health

Have you ever used anabolic steroids or undergone hormone replacement therapy? *

Previous Hormone Use

If so, what was your experience? *

Are you taking any medications or supplements that could interact with TRT or influence your hormone levels? *

Current Medications

Are you aware of the potential risks and side effects associated with TRT, such as increased risk of cardiovascular issues, prostate problems, and potential fertility impacts? *

Risk Tolerance

What are your primary goals for starting TRT ? *

Goals of Therapy

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Email *

Phone Number *

Any other ways to communicate with you? (Mention below)

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