Male BioTe Intake Form Male BioTe Paperwork "*" indicates required fields Step 1 of 4 25% EmailThis field is for validation purposes and should be left unchanged.Name* First Last Weight (lbs)*Birthday* MM slash DD slash YYYY Occupation*Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone*May we send messages via text regarding appointments to your cell? Yes No Emergency ContactName* First Last Phone*Relationship to Patient*Primary Care Physician's Name*Primary Care Physician's Phone Number and Address:*Marital Status Married Divorced Widow Living with Partner Single In the event we cannot contact you by the means you have 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. Please indicate their name, number and relationship to you below.*How did you hear about us?*GrouponFriendFamilyFacebookReal SelfTwitterGoogleInstagramYelpOtherIf selected "Friend" or "Family", please specify who referred you: Social HistoryCheck Any Areas That Apply:* I have completed my family My partner and I would like to have more children in the near future I have no biological children If you do not have biological children, have you tried to have children? Yes No If you have not had children, have you had prior semen analysis? Yes No HabitsI smoke cigarettes or cigars* Yes No If yes, how many do you smoke per day?I use e-cigarettes* Yes No If yes, how often do you use it per day?I use caffeine* Yes No If yes, how often do you use it per day?I drink alcoholic beverages* Yes No If yes, how often do you drink per week?Family HistoryCheck any that apply Heart Disease Diabetes Osteoporosis Alzheimer's or dementia Prostate cancer Male Medical HistoryAllergies to medications, latex or any other known allergies:*type NONE if you have no allergiesHave you ever had any issues with local anesthesia?* Yes No If yes, please explain:Please list any current medications (Oral and/or Topical) and/or vitamins:*(type NONE if you take no medications or vitamins)Current Testosterone Replacement? Yes No If yes, are you on estrogen blocker? Yes No Please specify current and past testosterone replacement therpy:*(type NONE if you have never done hormone replacement therapy)Surgeries. Please list all and when:*(type NONE if you have had no surgeries)Please list ANY other health related conditions, concerns or pertinent information not previously identified:*(type NONE if you have no conditions or concerns) Pertinent Medical/Surgical History* Cancer Elevated PSA Trouble passing urine Taking medicine for prostate or male-pattern balding History of anemia Vasectomy Erectile dysfunction Testicular or prostate cancer Prostate enlargement or BPH Kidney disease or decreased kidney function Frequent blood donations Non-cancerous testicular or prostate surgery Severe snoring Taking medication for high cholesterol None If you indicated cancer, please specify the type and year:Other Medical Conditions:* High Blood Pressure or Hypertension Heart Disease Atrial fibrillation or other arrythymia Blood clot and/or a pulmonary emboli Depression/anxiety Chronic liver disease (hepatitis, fatty liver, cirrhosis) Taking Proscar (finasteride), Flomax (Tamsulosin) or Avodart (dutasteride) Arthritis Hair thinning Sleep apnea High cholesterol Stroke and/or heart attack HIV or any thype of hepatitis Hemochromatosis Psychiatric disorder Thyroid disease Diabetes Lupus or other autoimmune disease None Other Sweating (night sweats or increased episodes of sweating)* Never Mild Moderate Severe Very Severe Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)* Never Mild Moderate Severe Very Severe Increased need for sleep or falls asleep easily after a meal* Never Mild Moderate Severe Very Severe Depressive mood (feeling down, sad, on the verge of tears, lack of drive)* Never Mild Moderate Severe Very Severe Irritability (mood swings, feeling aggressive, angers easily)* Never Mild Moderate Severe Very Severe Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)* Never Mild Moderate Severe Very Severe Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)* Never Mild Moderate Severe Very Severe Sexual problems (change in sexual desire, sexual activity, orgasm and/or satisfaction)* Never Mild Moderate Severe Very Severe Bladder problems (difficulty in urinating, increased need to urinate* Never Mild Moderate Severe Very Severe Erectile changes (weaker erections, loss of morning erections)* Never Mild Moderate Severe Very Severe Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)* Never Mild Moderate Severe Very Severe Difficulties with memory* Never Mild Moderate Severe Very Severe Problems with thinking, concentrating or reasoning* Never Mild Moderate Severe Very Severe Trouble thinking of the right word to describe persons, places or things when speaking* Never Mild Moderate Severe Very Severe Difficulty learning new things* Never Mild Moderate Severe Very Severe Increase in frequency or intensity of headaches or migraines* Never Mild Moderate Severe Very Severe Feels cold all the time or have cold hands or feet* Never Mild Moderate Severe Very Severe Hair loss, thinning or change in texture of hair* Never Mild Moderate Severe Very Severe Weight gain or difficulty losing weight despite diet and exercise* Never Mild Moderate Severe Very Severe Infrequent or absent ejaculations* Never Mild Moderate Severe Very Severe Feel cold all the time or have cold hands or feet* Never Mild Moderate Severe Very Severe Pellet Protocol InformationANTIDEPRESSANT WEAN PROTOCOL If you are taking an SSRI or SNRI antidepressant such as Prozac, Zoloft, Lexapro, Pristiq, Effexor, Viibryd, the generic equivalents or others and have NOT had long-term issues with generalized anxiety disorder, bipolar or major depressive disorders, you may be able to slowly wean off of your antidepressants. We recommend you wean off of these slowly as soon as you start to feel better with your pellets. This is usually after about 4 weeks and only if you are feeling better and ready to start the weaning process. These antidepressants have many side effects. You can feel tired, sleepy, have weight gain or difficulty achieving an orgasm (to name few) which is everything we are trying to improve. It is very difficult for the pellet therapy to have adequate results in some patients who are still on these medications. You are NOT deficient in these antidepressant medications. You are deficient in hormones. As we restore your hormone levels to normal with pellets, your symptoms of anxiety and/or depression should be relieved naturally. You should be able to wean off your antidepressant. Go slowly -- especially if you have been taking them for a while. While taking an SSRI or SNRI, your brain relies on these medications to get serotonin (the calming, feel good hormone) and doesn’t make its own. If you stop your medication abruptly, you can go through withdrawals. Symptoms of abrupt cessation may include headache, GI distress, faintness, body aches, chills, and strange sensations of vision or touch. Some patients withdrawing from Effexor may describe the feelings of “electric shocks”. You may also experience depression or anxiety symptoms returning. When you wean slowly, your brain has time to catch up, wake up, and start making its own serotonin again. If you are on a high-dose or capsule, you may have to request a lower dose to use in the transition. WE RECOMMEND THE FOLLOWING PROTOCOL TO HELP: 1. Take your pill every other day for 2 weeks. 2. Then every 3 days for 2 weeks. 3. Then every 4 days for 2 weeks and so on until you are down to one a week, then STOP. If at any point you feel badly or “off”, go back to the lowest dose you felt good on and take the wean a bit slower. If you are on a high dose of the medication, you may need an additional prescription for a lower strength so you can slowly transition from the higher to the lower strength and then wean as described above.
