• Testosterone Optimization

    Testosterone Optimization

    Pre-consultation Questionnaire
  • Birthday
     - -
  • Format: (000) 000-0000.
  • What is your preferred method of communication for clinical communication (appointments, prescriptions, etc). You may select more than one if you want communications sent in duplicate.

  • Past and Current Medical History

  • Current and Past Medical History/General
  • Current and Past Medical History/Cardiac*
  • Current and Past Medical History/Pulmonary*
  • Current and Past Medical History/Neurologic*
  • Current and Past Medical History/Gastrointestinal*

  • Past and Current Medical History

  • Current and Past Medical History/Urologic/Renal*
  • Current and Past Medical History/Autoimmune/Immunodeficiency*
  • Current and Past Neurodivergence*
  • Current and Past Mental Health*
  • Testosterone Questionnaire

    Testosterone Questionnaire

  • What is your biological sex (sex at birth)

  • With deepest apologies, we are unable to treat patients going through a transition.  We do not have the training or counseling abilities to best support you throught your transition.  We wish you the best of luck and hope you consider Creekside Retreat for any further needs.   

     

  • What symptoms are you having that made you suspect your Testosterone may be low
  • Have you had your testosterone levels checked in the past?
  • Current Testosterone Use

    Current Testosterone Use

  • Are you currently on any Testosterone Optimization?
  • Please Describe
  • What route?
  • Past Testosterone Use

    Past Testosterone Use

  • Have you used anything in the past for Testosterone Optimization?
  • Please Describe
  • What route?
  • What is your Fertility status?
  • Do you have a history of any of the following (please select all the apply)

  • Q-Adam Score

    *The qAdam score is an internationally recognized scoring system used to screen men for low testosterone.  We will use it to trend your progress.
  • Rows

  • What are your top 4 goals you hope to achieve with Testosterone Optimization

  • LABS

    Your current hormonal levels will dictate our treatment.  We will need to review the results during our consultation.   You will receive a link to schedule your consultation when your lab results are in.   

    Your order can be sent directly to the following labs or a printed lab order can be emailed.  You will be able to take this lab order to any lab.  This test is a blood test, fasting is not required.  

    For the most accurate results, please have your labs done first thing in the morning.  

     ***If you are currently on Testosterone Replacement you will need to stop it for 2 weeks prior to being tested.  

  • Testosterone Panel: 

    55 (cost at Creekside Retreat)

    The variability of insurance coverage of testing led us to encorporate this option.  Initial lab testing is $55.  This may or may not be less than your insurance.  We do not handle insurance claims or denials, however You can use an HSA card and/or submit the bill to your insurance for possible reimburesement.  This panel includes hormone evaluation as well and a complete metabolic profile, and complete blood count (CBC)

     

     ADDITIONAL LAB ADD ON

    Although not " for Testosterone evaluation, consider adding the following two additional lab bundles. The price listed is for labs done at Creekside.  I will also add them to any lab order, however I am unable to predict the cost due to the variation in lab charges and insurance coverage:

    Thyroid Panel: 

    45

    Thyroid health is deeply connected to overall hormonal balance, and testing can provide valuable insights if you’re experiencing unexplained symptoms despite addressing other hormone levels. Consider thyroid testing if you have persistent fatigue, unexpected weight changes, mood swings, hair thinning, or dry skin that doesn’t improve with standard interventions. 

    Vitality Essentials panel:

    50

    When assessing testosterone levels, it’s essential to understand how your overall health and nutrition may impact your hormonal balance. Adding the Vitamin D, B12, Folate, Ferritin, and Magnesium bundle provides valuable insights into key nutrients that play a critical role in energy, mood, muscle function, and overall vitality. Together with the CMP (comprehensive metabolic panel, which is included with your testosterone test), this bundle offers a well-rounded view of your nutritional status.

  • Would you like Thyroid testing added to your labs
  • How would you like your lab order?*

  • You will receive a paper order in your email!

  • You will be directed to schedule your lab draw after submission of this form.  You can also find the link to schedule on the Testosterone Patient Page / New Patient / Schedule Lab draw.

  • Preferred Lab
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Would you like to add-on either/both of these initial labs (can be ordered through your lab or drawn at Creekside)
  • Image field 364
  • Would you like to subscribe to our email list? ( emails will never be more than once a week, your information will NEVER be sold or shared, and you can unsubscribe at any time)
  • Should be Empty: