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BHRT Questionnaire

Please fill out the following medical assessment as honestly and accurately as possible. The medical provider will use the information to determine your best course of treatment.

"*" indicates required fields

Do you have a lack of energy?*

Yes

Are you sad and/or grumpy?*

Yes

Do you have a decrease in libido? (sex drive)*

Yes

Have you noticed a decrease in enjoyment of life?*

Yes

Have you noticed a decrease in strength and/or endurance?*

Yes

Are you falling asleep after dinner?*

Yes

Have you noticed a decrease in your ability to play sports?*

Yes

Has there been a recent deterioration in your work performance?*

Yes

Are your erections less strong?*

Yes

Have you lost height?*

Yes

Are you currently on any hormone therapy treatment?*

Yes

Are you currently experiencing any serious health conditions we should be aware of?*

Yes

Explain

Are you ready to get started with treatment if appropriate?*

Yes

Submit Your Answers.

1 in 4 men over the age of 30 are likely to have low testosterone.

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Last Name*

Email*

DOB*

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Phone

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Based on your answers, it looks like you might benefit from BHRT!

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