Enclomiphene Citrate Intake Form Template
Enclomiphene is the trans-isomer of clomiphene citrate, a selective estrogen receptor modulator (SERM) that stimulates endogenous testosterone production by blocking negative feedback on the hypothalamus and pituitary. Unlike traditional TRT, enclomiphene preserves fertility by maintaining LH and FSH levels. It is prescribed off-label through compounding pharmacies for hypogonadism, low testosterone, and as a fertility-preserving alternative to TRT. This intake form documents symptoms and collects the comprehensive history required for safe prescribing.
Free Template
Enclomiphene Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Enclomiphene Intake Form
1 General Patient Information
Please provide your personal information.
General Patient Information
Please provide your personal information.
First Name
Jane
Last Name
Smith
Date of Birth
—
Can you confirm you are 18 years or older?
Height
e.g. 5'8"
Weight
e.g. 170 lbs
2 Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Are you actively taking any medications? If so, please list them.
List all current medications, dosages, and frequencies
Do you have any medication allergies? If so, please list them.
List all known drug allergies and reactions
Are you currently being treated or have you been treated for any medical conditions? If so, please list them.
List all current and past medical conditions
Have you had any past surgeries? If so, please list them.
List all surgeries and approximate dates
What is/was your sex assigned at birth?
Male
Emergency contact name and phone number
Name — (555) 000-0000
Mailing address
123 Main St, City, State, ZIP
Any other questions or concerns?
Optional — share anything else you'd like your provider to know
3 Symptoms
Select all symptoms that currently apply to you.
Symptoms
Select all symptoms that currently apply to you.
4 Clinical Screening Questions
Please answer each question accurately. Your provider will review all responses.
Clinical Screening Questions
Please answer each question accurately. Your provider will review all responses.
Have you undergone total testosterone and hematocrit tests within the last 6 months?
Are you currently or have you previously been on testosterone replacement therapy (TRT), Clomid, or similar treatments?
Do you have a prescription from an external source and are you willing to discontinue it if prescribed?
Have you ever been diagnosed with or are you at high risk for strokes or blood clots?
Have you ever been diagnosed with any eye-related conditions or experienced visual disturbances?
Do you have a history of depression or other psychiatric conditions?
Have you been diagnosed with liver disease or dysfunction?
Are you currently undergoing any other forms of hormonal therapy or using supplements that could affect hormone levels?
Have you experienced any significant changes in weight or physical activity levels in the past six months?
Do you have a history of any endocrine disorders (e.g., thyroid disorders, adrenal gland disorders)?
Have you ever experienced any adverse reactions to medications similar to Enclomiphene?
Preview only. Your live form will include your branding and e-signature capture.
Compliance & Regulatory Notes
Review these notes before deploying this form in your practice.
Enclomiphene is not FDA-approved and is prescribed off-label. Documented informed consent is required. See FSMB: https://www.fsmb.org
Visual disturbances (blurring, scotomata) are a known side effect of clomiphene-class medications. Patients reporting visual changes should discontinue and seek ophthalmologic evaluation.
Baseline testosterone and hematocrit labs are recommended before initiating therapy and should be repeated at follow-up to monitor response. See Endocrine Society guidelines: https://www.endocrine.org/clinical-practice-guidelines
Enclomiphene must be compounded by a licensed pharmacy. See FDA: https://www.fda.gov/drugs/human-drug-compounding
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Sources & References
Frequently Asked Questions
How is Enclomiphene different from standard TRT?
Traditional TRT suppresses the HPG axis, reducing LH, FSH, and intratesticular testosterone, which impairs sperm production. Enclomiphene stimulates endogenous testosterone by blocking estrogen feedback without suppressing the HPG axis, preserving fertility.
Why are vision screening questions included?
Clomiphene-class medications (including enclomiphene) can rarely cause visual disturbances including blurred vision and scotomata. Patients with pre-existing eye conditions require closer monitoring, and visual symptoms during therapy require immediate evaluation.