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TRT Follow-Up Questionnaire – CY Men’s Health Clinic

CY Men’s Health Clinic — TRT Follow-Up Questionnaire

Structured follow-up for testosterone therapy: current dose, last injection, symptom response, side effects, safety screening, lab review, controlled-substance refill documentation, and chart-ready note generation.

TRT Follow-Up Safety Review Refill Readiness Note Generator

1. Patient Information

2. Current TRT Regimen

3. Symptom Response Since Starting / Last Visit

4. Side Effects Checklist

5. Safety / Red Flag Screening

Important: Positive red flags may require urgent evaluation, TRT hold, dose reduction, lab review, or referral.

6. Lab Review

7. Controlled Substance / Refill Review

8. Safety Summary / Refill Readiness

Click “Review Safety” or “Generar nota y crear PDF al mismo tiempo” to review safety flags and missing elements.
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Safety Level
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Refill Readiness
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Dose Action
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Follow-Up

9. Provider Assessment / Plan

10. Patient Handwritten Signature

Patient may sign below using mouse, finger, or stylus.

Sign inside the box above.

11. Generated Follow-Up Note

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

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