Dr. Russell LOW TESTOSTERONE questionnaire
Name: ______________________________________ Date of Birth: __________________________
Primary Care physician: ________________________
When and how were you diagnosed with low testosterone?
_____________________________________________________________________________________
Please circle any of the signs/symptoms you have below:
Low libido
poor muscle strength
Difficulty attaining erections
decreased shaving frequency
difficulty maintaining erections
change in size of your testicles
Do you have a history of blood clots?
 Yes
 No
Do you have problems with snoring at night, excessive daytime sleepiness or have you been
diagnosed with sleep apnea?
 Yes
 No
Have you ever used any testosterone supplementation?
 Yes, what brand and when? _________________________
 No
Are you currently interested in fathering a child?
 Yes, what brand and when? __________________________________________
 No
Illness/Medical History
Diabetes
Heart Disease
Thyroid Disease
Adrenal Disorder
Pituitary Disease
Osteoporosis
Calcium problem
Kidney disease
Stroke
Cancer (and what type)
High blood pressure
High cholesterol
Other
Yourself
Family Members
Details
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Please list any former surgeries and dates if known:
Surgeries:
Date:
Please list all medications, INCLUDING over the counter and herbal medications, with doses if known:
Medication
Dose
Frequency
Are you allergic to any medications? If so, what reaction did you have? _________________________
Social History:

Current smoker, if checked, how much and for how many years? _________________________

Smoked in the past, If checked, how much and for how many years? ______________________

Drink alcohol, If checked, how much and how often? ___________________________________
Marital Status: _________________________
Are you sexually active?
 Yes
 No
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Review of systems:
Please circle any CURRENT symptoms you are having on a FREQUENT basis
General
Fatigue, generalized weakness, weight loss, weight gain, abnormally thirsty
Head
Visual difficulty, double vision, blurred vision, change of voice, difficulty
swallowing, painful swallowing
Neck
Neck pain, neck swelling
Heart
Fast heart rate, palpitations, chest pain, shortness of breath with exertion
Lungs
Shortness of breath, cough, difficulty breathing when lying down, difficulty with
breathing when raising both arms above your head
Gastrointestinal
Abdominal pain, nausea, vomiting, diarrhea, constipation
Urinary
Frequent daytime urination, frequent nighttime urination, frequent urinary or
vaginal infections
Reproductive
For women: Last menstrual period _________, irregular periods, pregnant, post
menopausal (including surgical menopause)
For men: low libido, difficulty with erections, decreased shaving frequency
Skin
Dry skin, moist skin, rash, easy/excessive bruising, thin skin, excessive acne
For women only: male pattern hair growth
Blood
Prolonged bleeding, other blood disorders
Endocrine
Heat intolerance, cold intolerance
Musculoskeletal
Poor muscle strength, previous fracture, osteoporosis, previous foot ulcer, calf
cramping
Neurological
Burning/numbness/tingling of feet, tremors, jitteriness
Psychological
Depression, anxiety
Physical Examination:
Pulse
Resting Rate
Blood Pressure
Height
Weight
BMI
Eyes: pupils equal round and reactive to light, injection, proptosis, lid lag, stare, icterus
HEENT: moist mucus membranes, no oral lesions,
Lymphadenopathy: Palpable abnormal lymph nodes: ant/post cervical, supra/infra clavicular
Neck: Thyromegaly _________, trachea deviated
Heart: irregular rate _______, irregular rhythm,
Chest: lungs clear to auscultation, negative Pemberton’s sign
Abdomen: soft, nontender, good bowel sounds,
Musculoskeletal: grossly intact muscle strength, no tenderness to palpation along spine/hips, intact
distance between pelvic brim and lower ribs
Extremities: no edema, palpable peripheral pulses, onychomycosis toenails
Neurological: 2 + DTRs, intact monofilament/vibratory sensation, alert, oriented
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Skin: no ulcers on feet, dry skin, rash, jaundice
Psych: normal mood/affect, normal judgment
Other: ____________________________________________________________________________
Assessment/Plan:
Hypogonadism
We will check an early am LH, FSH, testosterone, cmp (for albumin) and SHBG to calculate a free
testosterone and determine whether this is primary vs secondary hypogonadism.
If secondary hypogonadism, we will check a pituitary MRI to rule out adenoma, and iron studies to rule
out hemochromatosis.
The pros/cons of different testosterone supplementations have been explained to the patient. He has
chosen: _____________________________________
In one month we will repeat early am labs.
Return to Clinic ___________________ Physician Signature: ___________________________________
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