Testosterone Cypionate Intake Form Template
Testosterone Cypionate is a long-acting injectable testosterone ester and one of the most commonly prescribed testosterone replacement therapy (TRT) medications in the United States. It is FDA-approved for hypogonadism and used off-label for andropause, sexual dysfunction, and body composition in men. This intake form documents hypogonadism symptoms, screens for absolute contraindications per FDA labeling, and collects identity verification required for controlled substance prescribing.
Free Template
Testosterone Cypionate Intake Form
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This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Testosterone Cypionate 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 Contraindications
Select all conditions that currently apply to you.
Contraindications
Select all conditions that currently apply to you.
5 Identity Verification
A government-issued photo ID is required for controlled substance prescribing.
Identity Verification
A government-issued photo ID is required for controlled substance prescribing.
Upload a photo of your driver's license or government-issued photo ID
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Compliance & Regulatory Notes
Review these notes before deploying this form in your practice.
Testosterone Cypionate is a Schedule III controlled substance. Prescribing requires DEA registration and compliance with the Ryan Haight Act for telehealth prescribing. See DEA: https://www.deadiversion.usdoj.gov
Prostate cancer and breast cancer are absolute contraindications per FDA labeling. PSA screening is recommended before initiating TRT in men over 40. See FDA Testosterone labeling: https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/085635s034lbl.pdf
Patients must be monitored for polycythemia (elevated hematocrit), cardiovascular risk, and prostate changes. Follow Endocrine Society monitoring guidelines: https://www.endocrine.org/clinical-practice-guidelines
Identity verification documents must be collected and retained per controlled substance prescribing requirements.
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Sources & References
Frequently Asked Questions
Why is identity verification required for TRT?
Testosterone is a Schedule III controlled substance. Federal law and state pharmacy regulations require identity verification before controlled substances can be prescribed, particularly via telehealth. A valid government-issued photo ID is required.
What monitoring is required during Testosterone Cypionate therapy?
Regular monitoring includes serum testosterone levels, hematocrit (polycythemia risk), PSA (prostate safety), lipid panel, and blood pressure. The Endocrine Society recommends testosterone checks at 3 and 6 months after initiation, then annually.