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Please enter your information.
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Do you authorize the release of information including appointments, records, treatments rendered, as well as financial and other relevant information to your Emergency Contact on an as-needed basis?
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Any Testosterone Replacement (TRT) History?
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Have you ever had your testosterone level measured?
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Are you currently using TRT or HRT?
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If yes, what therapy are you currently using?
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If other, please specify
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Symptoms
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Do you have problems with: (select all that apply)
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General Health
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Do you have or have you had: (select all that apply)
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If you selected any of the above, please provide more detail:
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Do you have or have you had: (select all that apply)
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Any History of Cancer?
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Do you have any of the following: (select all that apply)
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When did you have the condition(s) indicated above, if any?
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Did you receive or are you currently undergoing treatment for the condition(s) indicated above, if any?
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If yes, what type of treatment did you receive?
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If other, please specify
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Heart Health
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Do you have, or have you had, any of the following: (select all that apply)
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Sexual Health
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Are you sexually active?
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Have you ever had an STI (sexually transmitted infections)?
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If yes, please list the STIs that you have/had.
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Have you ever been tested for HIV?
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Are you HIV positive?
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Are you a Male?
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Would you like to have any children? Or, if you are already a father, would you like to have additional children?
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How do you rate your confidence that you could get and keep an erection?
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When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
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During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?
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During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
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When you attempted sexual intercourse, how often was it satisfactory for you?
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Prostatism Symptoms
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Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
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Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating?
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Over the past month, how often have you found you stopped and started again several times when you urinated?
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Over the past month, how often have you found it difficult to postpone urination?
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Over the past month, how often have you had a weak urinary stream?
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Over the past month, how often have you had to push or strain to begin urination?
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Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?
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Hospitalizations & Surgeries
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Please list all major surgeries you have had, including the year of surgery. If none, put N/A
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Please list all hospitalizations you have had, including the year of hospitalization. If none, put N/A
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Have you ever had any complications from anesthesia?
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If yes, please describe your anesthesia complications.
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Allergies, Medications, & Supplements
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Do you have any drug allergies?
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If yes, please list your drug allergies.
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Are you taking any medications?
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If yes, please list your medications and respective dosage and frequency.
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Are you taking any self-prescribed medications, supplements, or vitamins?
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If yes, please list any self-prescribed medications, supplements, and/or vitamins and respective dosage and frequency.
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Social History
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Do you use tobacco products?
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If yes, please list the tobacco products and respective frequency of use.
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If yes, how many years have you been using tobacco products?
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Do you use recreational drugs?
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If yes, which recreational drugs are you using and how often?
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Do you drink alcohol?
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If yes, how many drinks do you have per week on average?
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Primary Care Physician
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Do you have a Primary Care Physician (PCP)?
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If yes, what is your PCP's name, address, and phone number?
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If yes, do we have your permission to contact your PCP regarding your treatment, potential treatment, or health history?
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I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge.
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