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TRT Survey Copy
Step
1
of
14
7%
Please enter your name
(Required)
First
Last
Date of Birth (mm/dd/yyyy)
(Required)
MM slash DD slash YYYY
Email
(Required)
Phone
(Required)
Your answers to the following questions will help your doctor determine whether you are likely to benefit from Low T therapy.
Do you have a decrease in libido (sex drive)?
(Required)
Yes
No
Do you have a lack of energy?
(Required)
Yes
No
Do you have a decrease in strength and/or endurance?
(Required)
Yes
No
Have you lost height?
(Required)
Yes
No
Have you noticed a decreased "enjoyment of life?"
(Required)
Yes
No
Are you sad and/or grumpy?
(Required)
Yes
No
Are your erections less strong?
(Required)
Yes
No
Have you noticed a recent deterioration in your ability to play sports?
(Required)
Yes
No
Are you falling asleep after dinner?
(Required)
Yes
No
Has there been a recent deterioration in your work performance?
(Required)
Yes
No
Have you had any of the following symptoms?
Hot flushes and/or sweats
(Required)
Yes
No
Loss of facial, pubic, or body hair
(Required)
Yes
No
Breast enlargement
(Required)
Yes
No
Discharge from the nipples
(Required)
Yes
No
Inability to achieve erections
(Required)
Yes
No
Inability to maintain erections
(Required)
Yes
No
Loss of spontaneous morning erections (morning wood)
(Required)
Yes
No
infertility
(Required)
Yes
No
loss of vision
(Required)
Yes
No
loss of sense of smell
(Required)
Yes
No
How long have you experienced these symptoms?
(Required)
Less than a month
1 to 3 months
3 to 6 months
More than 6 months
Have you ever been exposed to any of the following?
(Required)
Chemotherapy
Testicular damage
Long-term opioid/narcotic use
Corticosteroid use lasting longer than one month
Anabolic steroids
None
Have you been diagnosed with any of the following medical conditions?
(Required)
Breast cancer
Polycythemia
Prostate cancer
Prostate enlargement (BPH)
Stroke
Heart condition
Sleep apnea
Other medical condition not listed here
No known medical conditions
Please list any medical condition(s) that you have been diagnosed with
(Required)
Please list any allergies to medications or other substances.
(Required)
(If none please type N/A)
Please list any prescription medications that you are currently taking on a regular or as-needed basis.
(Required)
Please list the names and why you take each medication (If none please type N/A)
If you have a photo of your pharmacy medication record, you can upload it here
Drop files here or
Select files
Max. file size: 10 MB.
Please list any over-the-counter (OTC) medications or health supplements that you take.
(Required)
Include the names and the reason you take each supplement. (If none please type N/A)
Are you contemplating or currently planning to initiate pregnancy?
(Required)
Yes
No
This is your opportunity to introduce yourself to your doctor and mention any comments about your condition in your words.
Upload a photo of government issued ID (e.g. drivers license).
Please make sure
Your ID is valid and within the frame
Your information is clearly visible If your ID does not have a current address. Please make sure to enter your current address below
File Upload
(Required)
Accepted file types: jpg, png, tiff, jpeg, pdf, Max. file size: 15 MB.
Is the address on your ID is your current address?
(Required)
Yes
No
What is your current address (shipping address)?
(Required)
Street Address
Address Line 2
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Do you have a provincial health card?
(Required)
Yes
I do not have a provincial health card.
Front of Health Card
(Required)
Accepted file types: jpg, png, tiff, jpeg, pdf, Max. file size: 15 MB.
Back of Health Card
(Required)
Accepted file types: jpg, png, tiff, jpeg, pdf, Max. file size: 15 MB.
Please provide the health card number as it appears on the card
Do you have coverage for medications through a private insurance plan?
(Required)
Yes
No
Please make sure
Your card is valid
Within the frame
Your information is clearly visible
Front of insurance card:
(Required)
Accepted file types: jpg, png, tiff, jpeg, Max. file size: 5 MB.
Back of insurance card:
(Required)
Accepted file types: jpg, png, tiff, jpeg, pdf, Max. file size: 5 MB.
Do you have additional coverage for medications through a 2nd private insurance plan?
(Required)
Yes
No
Front of insurance card:
(Required)
Accepted file types: jpg, png, tiff, jpeg, Max. file size: 5 MB.
Back of insurance card:
(Required)
Accepted file types: jpg, png, tiff, jpeg, Max. file size: 5 MB.
Please upload a selfie, ensuring your face is fully within frame, clearly visible, and not filtered in any way.
(Required)
Please make sure your face and shoulders are visible and well-lit.
Accepted file types: jpg, png, tiff, jpeg, pdf, Max. file size: 5 MB.