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HRT Patient Intake Questionnaire
First Name •
Last Name •
Address Line 1 •
Address Line 2
City •
State •
ZIP Code •
Phone Number •
Email Address •
How did you hear about Evolve? •
Preferred Method of Contact •
Gender •
Date of Birth •
Please upload a picture of your Driver's License •
Maximum file size: 40 MB
Primary Care Provider •
Personal Health History
Current Medical Problems
Prior Surgeries
Prior Hospitalizations
Vaccinations
Have you ever had a blood transfusion? •
Current Prescription Medications
Current OTC Medications
Medication Allergies
Personal Health History (Women)
Age at Menstruation Onset •
Date of Last Menstrual Cycle
Frequency of Menstrual Cycle (in days) •
Number of Pregnancies •
Number of Live Births •
Usual Cycle Duration •
Period Problems
Are you pregnant or breastfeeding? •
Have you had any bladder or kidney infections in the last year? •
Do you experience blood in your urine? •
Do you have problems with urinary control? (incontinence) •
Have you recently noted any breast lumps, tenderness, pain, skin change, or nipple discharge? •
What was the date of your last Pap smear? •
Personal Health History - Men
How many times do you get up to urinate each night? •
Do you experience burning or pain with urination? •
Is your urinary stream less forceful than usual? •
Are you experiencing difficulty urinating or completing urination? •
Do you experience blood in your urine? •
Have you had a bladder, kidney, or prostate infection in the past year? •
Have you recently noted any lumps, tenderness, swelling, or pain of your testicles? •
Have you ever had a rectal exam to examine your prostate? •
Approximate date of last prostate exam •
Result of prostate exam •
Health Habits
How often do you exercise and what types of training? •
Describe your diet. Do you follow any specific dietary guidelines? •
How much caffeine do you consume daily? •
How many alcoholic drinks to you consume in a week? •
Do you use tobacco products? •
How do you use tobacco? •
Amount •
Frequency •
Do you use marijuana? •
How do you use marijuana? •
Amount •
Frequency •
Do you use any recreational drugs? •
What recreational drug(s)? •
Drug Used •
How Often?
Amount •
Frequency •
Are you sexually active? •
How many times /  •
every ... •
Are you trying to get pregnant? •
Are you using birth control? •
What are you using for birth control? •
Family History
For first degree relatives (Mother, Father, Sisters, Brothers) list any medical history of diseases and if they are deceased, and the age they passed
Symptoms
Screening Questions
ADAM Questionnaire (Men Only)
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? •
EVE Questionnaire (Women Only)
Do you have hot flashes? •
Do you have a lack of energy? •
Do you have restless sleep or sleep disturbances? •
Do you have restless sleep or sleep disturbances? •
Have you noticed a decreased "enjoyment of life"? •
Are you moody or easily irritated? •
Do you have difficulty concentrating, or have short-term memory loss? •
Have you noticed muscle loss? •
Symptoms (check all that apply)
Do you have bladder leakage? •
Do you have excess body fat? •
High Risk Questions
Do you have any of the following skeletal symptoms?
Check all that apply
Additional Questions
Would you be interested in evaluating solutions for these pains? •
Do you have any of the following skin symptoms?
Check all that apply
Would you be interested in evaluating solutions for these problems? •
Have you ever been prescribed any type of hormone therapy? •
Please Explain •
Have you ever been on an HGH program? •
Please Explain •
Consent
Please write out your full legal name •
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