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Online Patient Intake Form – Testosterone Replacement Therapy (TRT)

Personal Information
Full Name*
Date of Birth*
Height*
Gender*
Current Weight (lbs)*
Desired Weight (lbs)*
Phone Number*
Email Address*
State*
City*
Fill required fields
Section 1: Symptoms of Low Testosterone
Check all that apply
Section 2: Medical History
Have you ever been diagnosed with low testosterone? *
Have you ever taken testosterone or hormone therapy before? *
If yes, when and for how long?
Do you currently take any medications or supplements?*
If yes, please list:
Do you have or have you had any of the following? (Check all that apply)*
Section 3: Lifestyle & Wellness
How often do you exercise? *
How many hours of sleep do you get per night? *
Do you smoke or vape? *
Do you consume alcohol regularly?*
Section 4: Goals of Therapy
Section 4: Goals of Therapy
Check all that apply*
Consent & Acknowledgment
Consent & Acknowledgment*
By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I understand that this questionnaire is used to determine candidacy for NAD+ and peptide therapy and does not replace a medical diagnosis or physician consultation.
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