Andropause Questionnaire

Bioidentical Testosterone Pellets for the Treatment of Andropause:

Is BioBalance bioidentical hormone pellet therapy right for you?

Are you a candidate for BioBalance bioidentical testosterone pellet therapy? Fill out our self-evaluation and we’ll let you know if BioBalance Health can help you “get your life back!”

We will e-mail our recommendations to you!

Name:
Email:
Phone Number:
Birthdate:
Occupation:

Symptoms
I am fatigued
I have insomnia
I have recent changes in my mood–new anxiety and/or depression
I have new onset of snoring
My sex drive has decreased
I no longer have spontaneous morning erections
I can no longer achieve orgasm
My testicles are getting smaller in size
I have tried Viagra and it worked
I have tried Viagra and it didn’t work
I am more irritable than I was a few years ago
I am getting fatter in the belly (pant size has increased)
I have developed increased “breast” size
My skin is dry
I can’t think as quickly as I used to
I can’t remember names of things and feel mentally foggy
My strength and exercise tolerance has diminished
My muscles are shrinking
I am balding quickly
My joints ache and I have a new onset of arthritic symptoms
My height is decreasing
Other:

Medical Status
I have completed my family
I have a history of using steroids for exercise performance
I have had a normal prostate exam and PSA in the last year
I have been treated for erectile dysfunction in the past
My cholesterol has recently increased
I have recently been treated for joint disease or arthritis

Medical Factors Affecting Possible Treatment
I have had testicular or prostate cancer
I have prostate cancer in my family
I have an elevated PSA
I have trouble passing urine or take Flomax, or Avodart
I have chronic liver disease (e.g., hepatitis, fatty liver, cirrhosis)
I have diabetes
I have had a stroke and/or a heart attack
I have had a blood clot and/or a pulmonary emboli
I smoke cigarettes or cigars
I drink more than 10 drinks of alcohol per week (definition?)
I am a recovering alcoholic
I use or have used marijuana in the last year
I am at least 20 pounds overweight
I have elevated lipids and/or take a cholesterol lowering medication

If you were referred by a physician, please enter his/her name here:

If you were not referred by a physician, how did you hear about BioBalance Health?

By completing this questionnaire and submitting it to BioBalance Health, you have indicated that you understand that this evaluation is only a screening tool to see if you are a candidate for hormone replacement therapy.

A face-to-face consultation in our office is necessary to complete your full evaluation.

Check here if you would like to receive new updates in treatment and therapy options.