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Pellet Insertion - Female
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Male patient presents for hormone pellet insertion.
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Initial vs Repeat
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If repeat - date last of last pellet insertion:
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SUBJECTIVE
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Symptoms of Low Testosterone Include:
• • •
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Pertinent Medical / Surgical / Social History / Family History
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OBJECTIVE
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Focused Physical Exam
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Labs
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Lab results are:
• • •
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Additional note about labs (if applicable):
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Pellet Insertion Procedure
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Pre-procedure discussion
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Insertion Site
• • •
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Skin Prepped with
• • •
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Local Anesthesia
• • •
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Procedure
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Pellets Inserted
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TESTOSTERONE Pellet Dose (mg / pellet)
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Number of Testosterone Pellets Inserted
• • •
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Total Testosterone Dose Inserted
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Testosterone Pellet LOT #(s):
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ASSESSMENT
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Diagnosis(es):
• • •
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PLAN
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Bio-Identical Hormone Therapy - Pellet Insertion (as described above)
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Post Procedure Instructions Provided (written & verbal):
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Follow- Up
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