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Male Hormone Replacement Therapy Intake Questionnaire
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Section 1 — Reason for Visit
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What are your main concerns or goals for treatment?
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How long have you had these symptoms?
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Have you ever had your testosterone checked?
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If so, when and what was the result if known?
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Section 2 — Symptom Checklist (ADAM questionnaire)
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Do you have a decrease in sex drive (libido)?
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Do you have a lack of energy?
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Do you have a decrease in strength and/or endurance?
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Have you lost height?
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Have you noticed decreased enjoyment of life?
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Are you sad and/or grumpy?
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Are your erections less strong?
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Have you noted a recent decline in your ability to play sports?
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Are you falling asleep after dinner?
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Has there been a recent deterioration in your work performance?
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Additional symptoms (check all that apply
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Section 3 — Medical History (check all that apply)
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Prostate / urinary
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Cancer
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Heart / blood vessels
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Sleep / breathing
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Hormone / metabolic
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Testicular / developmental
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Mental health
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Section 4 — Family History
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Select all:
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Section 5 — Fertility
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Do you plan to have children in the next 1–2 years?
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Do you have children now?
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Have you had fertility problems or a semen analysis?
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Section 6 — Medications and Substances
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List all medications and/or supplements that you currently take:
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Have you ever used (check all that apply):
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Any alcohol use?
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If so, how much per day?
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Recreational drugs
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If so which ones and how many times per week?
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List any allergies:
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Section 7 — Lifestyle
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Exercise:
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If so how many timers per week?
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Average sleep:
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Recent weight change?
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If so how much in the last 6 months:
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Stress level:
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Section 8 — Household Contacts (for topical testosterone)
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Do you live with or have regular skin contact with women or children?
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Section 9 — Treatment Preferences
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Preferred route if treatment is appropriate:
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Most important to you:
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