Male Hormone Replacement Therapy — New Patient Intake

Thank you for your interest in hormone replacement therapy at Kōena Integrative Medicine. Please complete this form thoroughly — your answers help us determine whether HRT is right for you. All information is confidential. A member of our team will follow up within 1-2 business days.

First name

Last name

Are you a current patient at Koena?

Yes

Birthday

Día

Mes

Año

Address

Phone

Height and Weight

Any drug allergies?

Current meds or supplements:

Do you smoke?

Yes

Quit

Are you currently using any hormone therapy? (if yes, what type)

Past hormone therapy? ( if yes, what and when)

List any surgeries and year

Medical History: check all that apply

Any other medical history we should know about?

Preventative care: check all that apply

Physical exam in the last year

PSA test in the last 12 months

Blood work in the last 12 months

Hormone delivery method preference

Pellets

Injectable

Topical

Not sure

MALE TESTOSTERONE CONSENT

Bio-identical testosterone is a hormone biologically identical to the testosterone your body produces naturally. Testosterone replacement therapy (TRT) has been shown in medical research to improve energy, libido, muscle tone, mood, mental clarity, and overall quality of life in men with testosterone deficiency.

All testosterone replacement therapy is subject to FDA regulations. Hormone pellet production is highly FDA regulated; however, the pellet insertion procedure is not an FDA approved procedure for hormone replacement.

SIDE EFFECTS may include but are not limited to:

- Pellet insertion: bleeding, bruising, swelling, pain, extrusion, infection, scarring at insertion site

- Testosterone: increased red blood cell count (erythrocytosis), acne, increased body hair, testicular shrinkage, temporary decrease in sperm production, prostate changes

IMPORTANT: If you are trying to father a child, please disclose this to your provider before starting testosterone therapy, as TRT may affect fertility.

Regular blood work including PSA and hematocrit levels will be required to monitor your therapy. Periodic dose adjustments may be necessary.

The safety of hormone therapy cannot be guaranteed for all individuals. Your eligibility will be determined following a thorough clinical evaluation. Submitting this form does not guarantee candidacy for hormone replacement therapy.

By typing my full name below I am providing my electronic signature and confirm all information on this form is accurate and complete to the best of my knowledge.

Signature

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