MPQH

Male Patient Questionnaire & History

Name: ____________________________________________________________Today’s Date: ____________

(Last)                                        (First)                                        (Middle)

Date of Birth: ______________ Age: ________ Occupation: _________________________________________

Home Address: _____________________________________________________________________________

City: ___________________________________________________ State: __________ Zip: _______________

Home Phone: _____________________ Cell Phone: _____________________ Work: ____________________

E-Mail Address: ___________________________________ May we contact you via E-Mail? (  ) YES  (  ) NO

In Case of Emergency Contact: ________________________________ Relationship: _____________________

Home Phone: _____________________ Cell Phone: _____________________ Work: ____________________

Primary Care Physician’s Name: ___________________________________ Phone: ______________________

Address: __________________________________________________________________________________

Address                                                   City                                                             State          Zip

Marital Status:     (   ) Married  (   ) Divorced  (   ) Widow  (   ) Living with Partner  (   ) Single

In the event we cannot contact you by the mean’s you’ve provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment.

Spouse’s Name: _____________________________________ Relationship: ____________________________ Home Phone: _____________________ Cell Phone: _____________________ Work: ____________________

Social: 

(   ) I am sexually active.

(   ) I want to be sexually active.

(   ) I have completed my family.

(   ) I have used steroids in the past for athletic purposes.

Habits: 

(   ) I smoke cigarettes or cigars ______________________ a day.

(   ) I drink alcoholic beverages ______________________ per week.

(   ) I drink more than 10 alcoholic beverages a week.

(   ) I use caffeine ______________________ a day.

Medical History

Any known drug allergies: ____________________________________________________________________

Have you ever had any issues with anesthesia?   (   ) Yes   (   ) No

If yes please explain: _________________________________________________________________________

Medications Currently Taking: _________________________________________________________________

Current Hormone Replacement Therapy: ________________________________________________________

Past Hormone Replacement Therapy: ___________________________________________________________

Nutritional/Vitamin Supplements: ______________________________________________________________ Surgeries, list all and when: __________________________________________________________________

Other Pertinent Information: __________________________________________________________________

__________________________________________________________________________________________

Medical Illnesses:                                                         

(   ) High blood pressure                                       (   ) Testicular or prostate cancer

(   ) High cholesterol                                              (   ) Elevated PSA

(   ) Heart Disease                                                   (   ) Prostate enlargement

(   ) Stroke and/or heart attack                            (   ) Trouble passing urine or take Flomax or Avodart

 (   ) Blood clot and/or a pulmonary emboli      (   ) Chronic liver disease (hepatitis, fatty liver, cirrhosis)

(   ) Hemochromatosis                                           (   ) Diabetes

 (   ) Depression/anxiety                                        (   ) Thyroid disease

(   ) Psychiatric disorder                                        (   ) Arthritis

(   ) Cancer (type): ____________________________       (   ) Other: ____________________________________

Year: _____________                      ____________________________________

I understand that if I begin testosterone replacement with any testosterone treatment, including testosterone pellets, that I will produce less testosterone from my testicles and if I stop replacement, I may experience a temporary decrease in my testosterone production. Testosterone Pellets should be completely out of your system in 12 months.

By beginning treatment, I accept all the risks of therapy stated herein and future risks that might be reported. I understand that higher than normal physiologic levels may be reached to create the necessary hormonal balance.

 

___________________________________  __________________________________________  ______________________

Print Name                                                                      Signature                                                                                             Today’s Date

 

BHRT CHECKLIST FOR MEN

Name:                                                                                                          Date:

                                                                                     

Mild   Moderate    Severe

Symptom (please check mark)                         Mild          Moderate          Severe          Never      

Decline in general well being                                                 

Joint pain/muscle ache                                                          

Excessive sweating                                                                 

Sleep problems                                                                       

Increased need for sleep                                                        

Irritability                                                                                

Nervousness                                                                           

Anxiety                                                                                    

Depressed mood                                                                    

Exhaustion/lacking vitality                                                     

Declining Mental Ability/Focus/Concentration                    

Feeling you have passed your peak                                       

Feeling burned out/hit rock bottom                                     

Decreased muscle strength                                                    

Weight Gain/Belly Fat/Inability to Lose Weight                   

Breast Development                                                              

Shrinking Testicles                                                                  

Rapid Hair Loss                                                                       

Decrease in beard growth                                                      

New Migraine Headaches                                                      

Decreased desire/libido                                                         

Decreased morning erections                                                

Decreased ability to perform sexually                                   

Infrequent or Absent Ejaculations                                         

No Results from E.D. Medications                                        

Other symptoms that concern you:                                       

 

 

Hormone Replacement Fee Acknowledgment

Preventative medicine and bio-identical hormone replacement is a unique practice and is considered a form of alternative medicine. Even though the physicians and nurses are board certified as Medical Doctors and RN’s or NP’s, insurance may not recognize it as necessary medicine BUT is considered elective and therefore may not covered by health insurance in most cases.

This practice is not associated with any insurance companies, which means they are not obligated to pay for our services (blood work, consultations, procedures or pellets). We require payment at time of service. After each paid visit, we will provide a form to send to your insurance company as a receipt showing that you paid out of pocket and including codes most commonly required. We will not, however, communicate in any way with insurance companies.

The form we provide is your responsibility to file with your insurance company, if so desired. All the information needed should be contained on the form.  We will not call, write, pre-certify, or make any contact with your insurance company. If we receive a check from your insurance company, we will not cash it, but instead return it to the sender. We will not respond to any letters or calls from your insurance company. If more information such as lab results or visit notes is requested, we can send directly to you and then you can submit to your insurance.

For patients who have access to Health Savings Account, you may pay for your treatment with that credit or debit card. This is the best idea for those patients who have an HSA/FSA as an option in their medical coverage.

 

New Patient Fee……………………………………………………………………. $125.00

Male Hormone Pellet Insertion Fee…………….…………………………. $700.00

 

We accept the following forms of payment:

All Major Credit Cards, Personal Checks and Cash.

 

 

___________________________________  ____________________________________________  ______________________

Print Name                                                                      Signature                                                                                             Today’s Date

 

 

Testosterone Pellet Insertion Consent Form

Bio-identical testosterone pellets are concentrated, compounded hormone, biologically identical to the testosterone that is made in your own body. Testosterone was made in your testicles prior to “andropause.” Bio-identical hormones have the same effects on your body as your own testosterone did when you were younger. Hormone pellets are made from soy and hormone replacement using pellets has been used in Europe, the US and Canada since the 1930’s. Your risks are similar to those of any testosterone replacement but may be lower risk than alternative forms. During andropause, the risk of not receiving adequate hormone therapy can outweigh the risks of replacing testosterone with pellets.

Risks of not receiving testosterone therapy after andropause include but are not limited to:

Arteriosclerosis, elevation of cholesterol, obesity, loss of strength and stamina, generalized aging, osteoporosis, mood disorders, depression, arthritis, loss of libido, erectile dysfunction, loss of skin tone, diabetes, increased overall inflammatory processes, dementia and Alzheimer’s disease, and many other symptoms of aging.

CONSENT FOR TREATMENT: I consent to the insertion of testosterone pellets in my hip. I have been informed that I may experience any of the complications to this procedure as described below. Surgical risks are the same as for any minor medical procedure and are included in the list of overall risks below:

Bleeding, bruising, swelling, infection and pain. Allergic reaction. Lack of effect (typically from lack of absorption). Thinning hair, male pattern baldness. Increased growth of prostate and prostate tumors. Extrusion of pellets. Hyper sexuality (overactive Libido). Ten to fifteen percent shrinkage in testicle size. There can also be a significant reduction in sperm production.

There is some risk, even with natural testosterone therapy, of enhancing an existing current prostate cancer to grow more rapidly.  For this reason, a rectal exam and prostate specific antigen blood test is to be done before starting testosterone pellet therapy and will be conducted each year thereafter.  If there is any question about possible prostate cancer, a follow-up with an ultrasound of the prostate gland may be required as well as a referral to a qualified specialist. While urinary symptoms typically improve with testosterone, rarely they may worsen, or worsen before improving. Testosterone therapy may increase one’s hemoglobin and hematocrit, or thicken one’s blood. This problem can be diagnosed with a blood test.   Thus, a complete blood count (Hemoglobin & Hematocrit.) should be done at least annually.  This condition can be reversed simply by donating blood periodically.

BENEFITS OF TESTOSTERONE PELLETS INCLUDE:

Increased libido, energy, and sense of well-being. Increased Muscle mass and strength and stamina. Decreased frequency and severity of migraine headaches. Decrease in mood swings, anxiety and irritability (secondary to hormonal decline). Decreased weight (Increase in lean body mass). Decrease in risk or severity of diabetes. Decreased risk of heart disease. Decreased risk of Alzheimer’s and Dementia.

I have read and understand the above.   I have been encouraged and have had the opportunity to ask any questions regarding pellet therapy.   All of my questions have been answered to my satisfaction. I further acknowledge that there may be risks of testosterone therapy that we do not yet know, at this time, and that the risks and benefits of this treatment have been explained to me and I have been informed that I may experience complications, including one or more of those listed above.   I accept these risks and benefits and I consent to the insertion of hormone pellets under my skin. This consent is ongoing for this and all future pellet insertions.

I understand that payment is due in full at the time of service. I also understand that it is my responsibility to submit a claim to my insurance company for possible reimbursement. I have been advised that most insurance companies do not consider pellet therapy to be a covered benefit and my insurance company may not reimburse me, depending on my coverage. I acknowledge that my provider has no contracts with any insurance company and is not contractually obligated to pre-certify treatment with my insurance company or answer letters of appeal.

___________________________________  ____________________________________________  ______________________

Print Name                                                                      Signature                                                                                             Today’s Date

 

Post-Insertion Instructions for Men

  • Your insertion site has been covered with two layers of bandages. Remove the outer pressure bandage any time after 3 to 4 hours. You may replace it with a bandage to catch any anesthetic that may ooze out.   The inner layer is either waterproof foam tape or steri-strips they should not be removed before 7 days.
  • We recommend putting an ice pack on the insertion area a couple of times for about 20 minutes each time over the next 4 to 5 hours.
  • Do not take tub baths or get into a hot tub or swimming pool for 3 days. You may shower but do not scrub the site until the incision is well healed (about 7 days).
  • No major exercises for the incision area for the next 7 days, this includes running, riding a horse, etc.
  • The sodium bicarbonate in the anesthetic may cause the site to swell for 1-3 days. Don’t worry…..this is normal.
  • The insertion site may be uncomfortable for up to 2 to 3 weeks. If there is itching or redness you may take Benadryl for relief, 50 mg. orally every 6 hours. Caution this can cause drowsiness!
  • You may experience bruising, swelling, and/or redness of the insertion site which may last from a few days up to 2 to 3 weeks.
  • You may notice some pinkish or bloody discoloration of the outer bandage. This is normal.
  • If you experience bleeding from the incision, apply firm pressure for 5 minutes.
  • Please call if you have any pus coming out of the insertion site or bleeding (not oozing) that is not relieved by pressure.
  • Remember to go for your post-insertion blood work 4 weeks after the insertion.
  • Most men will need re-insertions of their pellets 4-5 months after their initial insertion.
  • Please call as soon as symptoms that were relieved from the pellets start to return to make an appointment for a re-insertion. The charge for the second visit will be only for the insertion and not a consultation unless you would like to discuss treatment and additional hormonal health matters.

 

Reminders:

Please have your labs rechecked:

(   ) 6 weeks after your insertion

(   ) 2 weeks before your next insertion

(   ) Yearly

* Return for re-pelleting in 4 months Prescriptions:

(   ) DIM __________________ Directions ________________________________
(   ) Anastrozole ____________ Directions ________________________________
(   ) Vitamin D _____________ Directions ________________________________
(   ) Other ________________ Directions ________________________________

 

___________________________________  ____________________________________________  ______________________

Print Name                                                                      Signature                                                                                             Today’s Date

 

WHAT MIGHT OCCUR AFTER A PELLET INSERTION

A significant hormonal transition will occur in the first four weeks after the insertion of your hormone pellets. Therefore, certain changes might develop that can be bothersome.

  • FLUID RETENTION: Testosterone stimulates to the muscle grow and retain water which may result in a weight change of two to five pounds. This is only temporary. This happens frequently with the first insertion, and especially during hot, humid weather conditions.
  • SWELLING of the HANDS & FEET: This is common in hot and humid weather. It may be treated by drinking lots of water, reducing your salt intake, taking cider vinegar capsules daily, (found at most health and food stores) or by taking a mild diuretic, which the office can prescribe.
  • MOOD SWINGS/IRRITABILITY: These may occur if you were quite deficient in hormones and/or imbalanced. They will disappear when hormone levels are optimized.
  • FACIAL BREAKOUT: Some pimples may arise if the body is very deficient in testosterone. This lasts a short period of time and can be handled with a good face cleansing routine, astringents and toner. If these solutions do not help, please call the office for suggestions and possibly prescriptions.
  • HAIR LOSS: Is rare and usually occurs in patients who convert testosterone to DHT. Dosage adjustment generally reduces or eliminates the problem. Prescription medications may be necessary in rare cases.
  • HAIR GROWTH: Testosterone may stimulate some growth of hair on your chin, chest, nipples and/or lower abdomen. This tends to be hereditary. You may also have to shave your legs and arms more often. Dosage adjustment generally reduces or eliminates the problem.

 

 

 

___________________________________  ____________________________________________  ______________________

Print Name                                                                      Signature                                                                                             Today’s Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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