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TRT Questionnaire

HomeTRT: Total Recalibration for Modern MenTRT Questionnaire

Current Medical Issues *

Primary Care Provider Name

Primary Care Provider Phone Number

Current Prescription Medications *

Current OTC Medications / Supplements *

Allergies *

Prior Surgeries *

Do you currently experience any of the following? (Select all that apply) *Decreased sex drive (libido)Low energy or fatigueDecreased strength or enduranceLoss of heightMood swings / irritability / sadnessWeaker erectionsReduced sports performanceDifficulty focusing at workFalling asleep after mealsAnxietySleep difficulty or insomniaSexual dysfunctionDifficulty completing urinationLumps, pain, swelling, or tenderness in testicles

Night-time Urination Frequency (Times per night)

Prostate Exam Results (if applicable)

Do you plan to have children? *YesNoUnsure

Current Exercise Routine

Diet Model or Eating Style

Tobacco Use *NeverOccasionallyDaily

Caffeine / Stimulant / Pre-Workout Use *

Recreational Drug Use *

What does your dream outcome from working with us look like? *

What is your estimated monthly budget toward health optimization? *R1000–R2000R2000–R4000R4000–R6000R6000+

Full Name *

Email Address *

Phone *

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Defibrillator
Diagnostic Medical Supplies
Emergency and Trauma Equipment / Orthopedic
Face Mask
Gloves
Hospital Equipment
Medical Instruments
Medical Supplies
Oxygen
Protective Wear
Sanitizer
Sterilization
Syringes & Needles
Thermometers

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