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The Medicine Shoppe 1405 NE Douglas Lee's Summit, MO 64086 Phone: 816-524-8444 Fax: 816-246-5493
Male BHRT Symptom Update
Date
Name______________________________________________
Date of Birth
Address Home Phone (
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Cell Phone (
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Have there been any changes in any of your medications in the past year? If so, please list:
Please check all symptoms below that apply (this is very important to the evaluation process) Symptoms of low Progesterone? __ Acne __ Headaches __ Anxiety/Irritability ___per week __ Weight Gain __ Low Sex Drive __ Mood Swings __ Depression __ Food Cravings __ Fuzzy Thinking __ Joint Pain __ Low Energy Symptoms of low Testosterone? __ Depression __ Urinary Incontinence __ Erectile Disfunction __ Low Energy __ Joint Pain __ Low Sex Drive __ Heart Palpitations __ Thinning Skin __ Fibromyalgia
Other symptoms? __ Insomnia
__ Inability to Climax __ Bone Loss __ Memory Lapses __ Muscle Weakness
Other Symptoms Have any symptoms become more frequent/bothersome in the past few months?
Signing here gives the pharmacist permission to make dosing change suggestions to your physician. X ___________________________________________________Date: ___________________