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Day 2 and TRT Transfer Selected for Transfer Patients
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Patient History
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Day 1 Hormone Therapy
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Day 2 Hormone Therapy
|
|
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Transfer TRT Patient
|
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NP Weight Loss
|
|
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GLP-1 Weight Loss
|
|
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Non-GLP-1 Weight Loss
|
|
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EKG History
|
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Vitamin Therapy
|
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Aesthetics
|
|
|
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PRP
|
|
Patient History
|
|
|
No Contraindications Noted On Day 1
|
Contraindications Noted On Day 1
|
|
|
List Contraindications
|
|
Medical History
|
|
|
Patient Medical History
|
|
|
Vitamin Therapy Prior Use History
|
Vitamin Therapy No Prior Use History
|
|
Past Medical History
• • •
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Past Medical History Freewrite
|
|
Past Surgical History
• • •
|
Comments
|
|
Childhood illnesses
• • •
|
Comments
|
|
Childhood Immunizations
• • •
|
Comments
|
|
Date of last PE
|
|
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PCP
|
PCP Contact Information
|
|
Prior Hormone Replacement Medication and Dose
|
|
|
Familial Medical History
|
|
|
Family History
|
|
|
Paternal Medical History
• • •
|
|
|
Maternal Medical History
• • •
|
|
|
Social History
|
|
|
Social History
|
|
|
Marital Status
• • •
|
|
|
Living Arrangements
• • •
|
|
|
Occupation
|
|
|
Additional Relevant Social Hx
|
|
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Relevant History
|
|
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Caffeine Intake
|
|
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Alcohol Intake
|
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Other Substances
|
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Patients Diet
|
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