Male BHRT Questionnaire

Full Name *

Age *

Date Of Birth *

Weight (lbs) *

Height (ft/in) *

BMI (if known)

Are you currently taking a 5-alpha reductase medication? (Examples: finasteride [Propecia, Proscar], dutasteride [Avodart], or dutasteride/tamsulosin [Jalyn]) *

Yes

Do you have a history of prostate cancer? *

Yes

Have you ever had a urological evaluation or work-up? *

Yes

If yes, was it normal?

Yes

Are you currently being treated as a chronic pain patient? *

Yes

Do you currently smoke? *

Current smoker

Former smoker

Never smoked

Are you currently on testosterone therapy (injections, pellets, gels, or patches)? *

Yes

Uncertain

Are you currently taking ADD/ADHD medications (e.g., Adderall, Ritalin, Concerta, Vyvanse)? *

Yes

Are you currently taking blood thinners / anticoagulants (e.g., warfarin [Coumadin], apixaban [Eliquis], rivaroxaban [Xarelto], clopidogrel [Plavix])? *

Yes

Are you currently taking oral steroids (e.g., prednisone, methylprednisolone, dexamethasone)? *

Yes

Are you currently taking immunosuppressant medications (e.g., methotrexate, azathioprine [Imuran], cyclosporine, tacrolimus)? *

Yes

Are you currently receiving chemotherapy? *

Yes

Please list any other prescription medications you are currently taking:

Activity level: *

Yes

Do you experience low libido or erectile dysfunction? *

Yes

Do you experience fatigue? *

Yes

Do you have sleep problems (difficulty falling or staying asleep)? *

Yes

Do you experience brain fog or memory issues? *

Yes

Do you experience depression, anxiety, or emotional exhaustion? *

Yes

Do you experience joint or muscle discomfort? *

Yes

Have you had recent weight gain? *

Yes

Any Additional Comments, Questions Or Special Requests?

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