Male Hormone Optimization Medical Activation Form
Complete your medical history, goals, timeline, symptoms, and de-identified lab details for provider review.
Identity and Completion
Unique ID
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Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical History
What are you hoping to address with this visit?
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Low energy
Low libido
Erectile concerns
Mood changes
Weight gain
Muscle loss
Sleep concerns
Fertility concerns
Brain fog
Other
Describe your symptom timeline and when you first noticed these concerns
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List any current medical conditions and whether you are currently seeing another provider for this concern
Medication, Supplement, Hormone, and Allergy History
Current or recent medication, supplement, peptide, or hormone categories
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Prescription medications
Over-the-counter medications
Vitamins or minerals
Herbal or botanical supplements
Peptides or injections
Hormones or hormone-related therapies
Other
Prior testosterone, hCG, SERM, aromatase inhibitor, or anabolic androgen use
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Testosterone replacement therapy
Anabolic steroid or performance-enhancing androgen use
hCG use
SERM use (e.g., clomiphene, tamoxifen)
Aromatase inhibitor use
None of the above
Other
Hair-loss or finasteride/dutasteride medication history
Finasteride
Dutasteride
Topical hair-loss treatment
None
Other
Fertility-related treatment history
Semen analysis
Sperm preservation or banking
Fertility medications
Assisted reproductive treatment
None
Other
List current and recent medications, supplements, peptides, and hormones with dose and frequency
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Medication, supplement, or hormone allergies and prior adverse reactions
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Which of the following medical conditions have you had or been diagnosed with?
Cardiovascular disease
High blood pressure
Clotting disorder
Stroke or TIA
Sleep apnea
Prostate enlargement/BPH
Elevated prostate screening result
Prostate cancer
Breast cancer
Liver disease
Kidney disease
Diabetes
Thyroid disease
Depression or anxiety
Bipolar disorder
Other psychiatric condition
Seizures
Head injury or concussion
Infertility
None of these
Symptoms
Select any symptoms or concerns that apply
Low libido
Erectile concerns
Morning erections changes
Urinary symptoms
Prostate concerns
Gynecomastia or breast tenderness
Low energy
Mood changes
Cognitive concerns
Sleep concerns
Strength loss
Increased body fat
Difficulty building muscle
Frequent urination
Weak urine stream
Getting up at night to urinate
No current concerns
Other
Reproductive Goals
Which best describes your current reproductive goal?
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Try to conceive soon
May want children in the future
Do not want children
Already completed family
Prefer not to say
If fertility preservation is important, which options would you like to discuss?
Semen analysis
Sperm preservation
Referral to fertility specialist
Medication options with lower fertility impact
Not sure yet
Other
Lifestyle and Vitals
Smoking status
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Never
Former
Current
Prefer not to say
Alcohol use
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None
Occasional
Weekly
Daily
Prefer not to say
Substance use
Cannabis
Nicotine vaping
Recreational stimulants
Opioids
None
Other
Vitals
Labs and Attachments
Date of most recent labs
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Available lab results and key values (include test name, value, units, and date)
De-identified Supporting Records
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Urgent Red-Flag Screening and Acknowledgement
Are you currently experiencing any of the following urgent warning signs? If yes, seek emergency care now or call emergency services immediately rather than waiting for form review.
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Chest pain
Severe shortness of breath
One-sided calf swelling or pain
Stroke symptoms (face droop, arm weakness, speech trouble)
Fainting or near-fainting
Severe headache or sudden vision change
Thoughts of self-harm
Severe agitation or aggression
Difficulty urinating or inability to urinate
None of the above
Other emergency symptoms
Signature
Signature
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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