Visit type: trtFollowup
First name
(Required)
Last name
(Required)
Email
(Required)
Phone
(Required)
Date of birth
(Required)
What was your sex assigned at birth?
(Required)
Male
Female
Please identify all your current medical conditions
(Required)
Please list all your current medications including dosages
(Required)
Please list all of your known allergies
(Required)
What is your height in feet and inches? (Feet)
(Required)
What is your height in feet and inches? (Inches)
(Required)
What is your weight in pounds?
(Required)
Have there been any health changes, medication changes, ED visits or hospitalizations since your last check-in?
(Required)
No
Yes
Please tell us more about the changes in your health
In the past 72 hours, have you experienced any of the following: Chest pain or shortness of breath; Severe dizziness or fainting; Facial swelling, rash, or hives; Thoughts of self-harm or feeling unsafe
(Required)
Yes
No
These are concerning symptoms that should prompt immediate medical evaluation. Please contact EMS services immediately for further evaluation.
Have you experienced any side effects from the current medication?
(Required)
No
Yes
Please tell us more about the side effects you are experiencing
Are you noticing a decrease in testicular size or fullness?
(Required)
Yes
No
Please enter the exact date you last administered your testosterone dose. Accurate timing helps us safely determine your next scheduled dose.
(Required)
Has your dose been adjusted by another provider or have you self adjusted your dose since your last visit?
(Required)
Yes, this has been adjusted
No, I am taking the same dose that was prescribed during my last appointment
Please provide more information about who adjusted your dose, why this was adjusted, and what is your current dose?
Since your last visit, how would you rate your libido (sex drive)?
(Required)
Terrible
Poor
Average
Good
Excellent
Since your last visit, how would you rate your energy level?
(Required)
Terrible
Poor
Average
Good
Excellent
Since your last visit, how would you rate your strength or endurance?
(Required)
Terrible
Poor
Average
Good
Excellent
Since your last visit, how would you rate your enjoyment of life?
(Required)
Terrible
Poor
Average
Good
Excellent
Since your last visit, how would you rate your overall happiness or mood?
(Required)
Terrible
Poor
Average
Good
Excellent
Since your last visit, how strong are your erections?
(Required)
Extremely weak
Weak
Moderate
Strong
Extremely strong
Since your last visit, how would you rate your work performance over the past 4 weeks?
(Required)
Terrible
Poor
Average
Good
Excellent
Since your last visit, how often do you fall asleep after dinner?
(Required)
Never
1-2 times per week
3-4 times per week
5-6 times per week
Every night
Since your last visit, how would you rate your sports or physical performance over the past 4 weeks?
(Required)
Terrible
Poor
Average
Good
Excellent
How much height have you lost?
(Required)
2 inches or more
1.5-1.9 inches
1-1.4 inches
0.5-0.9 inches
None (0-0.4 inches)
What other information or questions do you have for the doctor?
TRT, HCG, and SERM-Based Therapy Informed Consent
(Required)
I have read the above information and I do consent and wish to move forward
I have read the above information and I do not wish to continue
Please read the full consent document above before selecting.
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