• 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.  

  • 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
  • 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)

  • Men's Health Consultation

  • Men's Health Consultation 

    Includes:

    • Complete review of your symptoms and health history

    • Appropriate order and in depth review of labs

    • Evaluation of metabolic health and hormomal health with recommendations which may include hormones, peptides and supplements.

  • *

    prevnext( X )
    Initial Consultation Fee Product Image
    Initial Consultation Fee


    $175.00$175.00
      
    Total
    $0.00$0.00
    Debit or Credit Card
  • Should be Empty: