Male HRT Screening Questionnaire

Please Fill in the contact fields and answer the following questions.

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

Do you have a lack of energy?

Do you have a decrease in strength and/or endurance?

Have you lost height?

Have you noticed a decreased "enjoyment of life"

Are you sad and/or grumpy?

Are your erections less strong?

Have you noticed a recent deterioration in your ability to play sports?

Are you falling asleep after dinner?

Has there been a recent deterioration in your work performance?

History of coronary artery disease (prior heart attack, stents, or CABG)?

History of congestive heart failure?

History of stroke or TIA?

Uncontrolled Hypertension?

History of prostate cancer?

History of breast cancer?

Untreated sleep apnea (No CPAP)?

Elevated hemoglobin?

BPH (benign prostate hypertrophy)?

Known PSA over 4?

Are you age 65 or older?