TRT Patient Intake Form Template
A thorough patient intake form is essential for any testosterone replacement therapy program. This template captures the clinical information providers need to evaluate testosterone deficiency, screen for contraindications, and determine appropriate treatment. Designed for hormone clinics, men's health practices, and primary care providers offering TRT, this form includes validated symptom assessment criteria, required baseline lab documentation, cardiovascular risk screening, and fertility impact counseling. All sections align with Endocrine Society Clinical Practice Guidelines and AUA recommendations for testosterone therapy.
Form Preview
Section 1 of 6
Patient Demographics
Please provide your contact information.
Full Name *
John Doe
Date of Birth *
...
Biological Sex *
Male
Phone Number *
(555) 000-0000
Email Address *
Address *
123 Main St, City, ST 00000
Primary Care Physician
...
Section 2 of 6
Symptom Assessment
Check any symptoms you've been experiencing.
Select all symptoms you are currently experiencing
How long have you experienced these symptoms? *
Less than 3 months
Rate symptom severity (1-10) *
1
Section 3 of 6
Medical History & Contraindications
Please check any conditions you have or have had.
Medical History
Do you plan to father children in the near future?
Previous testosterone or anabolic steroid use
If yes, describe previous hormone use
Type, dose, duration, prescribing provider
Section 4 of 6
Current Medications & Supplements
Please list everything you're currently taking.
Current Medications *
List all medications with dosages
Current Supplements
Vitamins, herbal supplements, performance supplements
Known Allergies *
Medications, foods, latex
Are you allergic to any of the following?
Section 5 of 6
Baseline Lab Work
Please provide any recent lab work if available.
Have you had testosterone levels checked?
Upload Recent Bloodwork Panel (optional)
Attach file or bring to appointment
Section 6 of 6
Lifestyle & Goals
Help us understand your goals and lifestyle.
Primary Treatment Goal *
Increase energy and reduce fatigue
Exercise Frequency *
Sedentary
Smoking / Tobacco Status *
Never
Alcohol Use *
None
This is a preview. Actual form will be customized with your practice branding.
Compliance & Regulatory Notes
The Endocrine Society recommends diagnosing testosterone deficiency only after two morning serum testosterone measurements showing levels below 300 ng/dL, combined with clinical symptoms. See guidelines: https://academic.oup.com/jcem/article/103/5/1715/4939465
Testosterone therapy is contraindicated in patients with prostate or breast cancer, uncontrolled heart failure, untreated severe sleep apnea, or hematocrit above 50%. Screen for these conditions before initiating treatment.
Patients considering future fertility must be counseled that exogenous testosterone suppresses spermatogenesis. Alternative treatments (e.g., clomiphene, hCG) should be discussed. This counseling must be documented.
Baseline PSA and hematocrit are required before initiating TRT. Monitor hematocrit at 3-6 months and annually thereafter; suspend therapy if hematocrit exceeds 54%.
Testosterone is a Schedule III controlled substance under the Controlled Substances Act. Prescribing must comply with DEA regulations and state-specific controlled substance prescribing requirements. See DEA: https://www.deadiversion.usdoj.gov
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Frequently Asked Questions
What lab work is required before starting TRT?
At minimum, two morning total testosterone levels, free testosterone, PSA, hematocrit/CBC, lipid panel, and a comprehensive metabolic panel. The Endocrine Society requires two confirmed low morning testosterone measurements before diagnosis.
Can this form be used for female testosterone therapy?
This form is primarily designed for male TRT. Female testosterone therapy has different dosing, indications, and monitoring requirements. We recommend using the HRT Patient Intake Form for female patients, which covers testosterone as part of broader hormone replacement.
Should I screen for fertility concerns in the intake form?
Yes. Exogenous testosterone suppresses sperm production and can cause infertility. All male patients of reproductive age must be asked about fertility plans before initiating TRT. This is both a clinical best practice and important for liability protection.
What monitoring is required during TRT?
Monitor testosterone levels, hematocrit, PSA, and liver function at 3-6 months after initiation, then annually. If hematocrit exceeds 54%, therapy should be suspended. Adjust dosing based on clinical response and lab values.