CY Men’s Health Clinic – TRT Intake Form

CY Men’s Health Clinic — TRT / Men’s Health Intake

Structured intake for testosterone deficiency screening, safety review, controlled-substance documentation, required labs, handwritten signature, and automatic chart-ready note generation.

TRT Intake Safety Screening Signature Pad Note Generator

1. Patient Information

Patient Name

Date of Birth

Age

Date

Phone

Preferred Language

Preferred Pharmacy

Pharmacy Address / Phone

Visit Type

Patient Location During Telemedicine Visit

2. Reason for Visit

Low energy / fatigue Low libido Erectile dysfunction Decreased morning erections Difficulty building muscle Loss of strength Weight gain Increased belly fat Low motivation Depressed mood Irritability Brain fog / poor concentration Poor sleep Interest in testosterone therapy Already on TRT / continuation of care

Symptom Duration

Functional Impact

Other Reason

3. Testosterone / Hormone History

Prior Low Testosterone Diagnosis?

Prior Testosterone Therapy?

Previous TRT Type

Testosterone cypionate injections Testosterone gel Pellets Cream Clomid / clomiphene HCG

Current / Previous Dose

Last Use Date

Prior Prescriber / Clinic

Non-prescribed anabolic/testosterone use?

If yes, explain

4. Treatment Goals

Improve energy Improve libido Improve erections Improve mood Improve motivation Improve muscle mass Lose fat Improve exercise performance Improve sleep Continue previous TRT

What would make treatment successful?

5. Symptom Checklist

Sexual / Reproductive

Low sex drive Erectile dysfunction Fewer morning erections Trouble maintaining erection Infertility concerns Testicular shrinkage Breast tenderness Gynecomastia

Energy / Mood / Cognitive

Fatigue Low motivation Depressed mood Anxiety Irritability Mood swings Poor concentration Brain fog

Physical / Sleep

Weight gain Loss of muscle mass Decreased strength Poor sleep Snoring Witnessed pauses in breathing Daytime sleepiness Fluid retention / swelling

6. Medical History & Contraindication Screening

High blood pressure High cholesterol Diabetes Prediabetes Obesity Heart disease Heart attack Stroke Blood clots / DVT / PE Sleep apnea BPH / enlarged prostate Prostate cancer Elevated PSA Male breast cancer Liver disease Kidney disease Thyroid disease Pituitary disorder Testicular injury / surgery Infertility Bipolar disorder Substance use disorder

Other Medical Conditions

Surgeries / Hospitalizations

7. Prostate / Urinary Screening

Frequent urination Waking up at night to urinate Weak urinary stream Difficulty starting urination Incomplete bladder emptying Pain/burning with urination Blood in urine Family history of prostate cancer

Ever Seen Urologist?

Reason / Findings

8. Fertility Screening

Trying to Have Children?

Has Children?

Understands TRT May Reduce Fertility?

Wants Fertility-Preserving Discussion?

Fertility Notes

9. Medications, Allergies & Family History

Current Medications / Supplements

Medication Allergies

Medication Categories

Blood thinners Opioid pain medications Steroids / prednisone Psychiatric medications Blood pressure medications Diabetes medications Prostate medications Sleep medications ED medications Bodybuilding/testosterone supplements

Family History

Prostate cancer Heart disease Heart attack Stroke Blood clots Diabetes Hypertension High cholesterol Low testosterone Infertility

10. Social History

Smoking

Vaping

Alcohol Use

Recreational Drug Use

Exercise

Diet

Occupation

Additional Social Notes

11. Sleep Apnea Screening

Loud snoring Daytime tiredness/sleepiness Observed pauses in breathing High blood pressure Large neck / significant obesity Diagnosed sleep apnea Uses CPAP Has CPAP but does not use it

Prior Sleep Study?

Result

12. Cardiovascular & Acute Safety Screening

Events in Last 6 Months

Heart attack Stroke Chest pain Uncontrolled blood pressure Heart failure hospitalization Blood clot Severe shortness of breath None of the above

Current Symptoms

Chest pain Severe shortness of breath Leg swelling Calf pain Rapid heartbeat Dizziness / fainting None of the above

13. Lab History & Required TRT Labs

Prior Testosterone Labs?

Prior Total Testosterone #1

Date/Time #1

Prior Total Testosterone #2

Date/Time #2

Hematocrit / Hgb

PSA

Blood Pressure

Labs Available / Ordered

Total testosterone AM #1 Total testosterone AM #2 CBC / hematocrit CMP / liver/kidney function PSA Lipid panel Hemoglobin A1c LH FSH Prolactin SHBG Free testosterone Estradiol TSH

Additional Lab Notes

14. Patient Acknowledgment / Consent Elements

These checkboxes help document that required counseling elements were reviewed. A separate formal consent form may still be used.

TRT only when medically appropriate Testosterone is controlled medication Labs required before/during treatment No treatment if required labs missing TRT may affect fertility TRT may increase hematocrit May worsen untreated sleep apnea PSA/prostate monitoring may be needed No refills if follow-up/labs missed Do not share/sell/transfer medication Early refills may not be approved Clinic may stop TRT for safety/non-compliance Telemedicine limitations reviewed Physical location verified for telemedicine Emergency/urgent care instructions reviewed

Consent Signed?

PMP Reviewed?

Records Requested/Reviewed?

15. Patient Handwritten Signature

Patient may sign below using mouse, finger, or stylus. This documents acknowledgment on this intake. A separate formal consent may still be used by the clinic.

Patient Signature Name Printed

Signature Date

Signature Captured?

Sign inside the box above.

16. Provider Review / Clinical Decision

Click “Generate Intake Note” to review safety flags and missing elements.

Symptoms Consistent With Testosterone Deficiency?

Contraindications Present?

Candidate Status

Initial / Continued TRT Plan

Follow-up Interval

Next Lab Timing

Provider Assessment / Additional Plan

Generated Intake Note

Use this as a draft. Review clinically before saving in the EHR.