About Faculty and Advisory Board Join the Team Therapy What is BHRT? Signs & Symptoms Benefits of Pellet Therapy Frequently Asked Questions Women Men Blog Contact Find a Provider Become a Provider
BHRT Checklist for Men Privacy Policy 40% Complete (success) First Name * Last Name * Email * Phone * What is the best way to contact you? Email Phone Text What is the best time to reach you? Address City State/Province/Region Zip/Postal Code * Country Please select oneAfghanistan≈land IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas (the)BahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean Territory (the)Brunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman Islands (the)Central African Republic (the)ChadChileChinaChristmas IslandCocos (Keeling) Islands (the)ColombiaComoros (the)Congo (the Democratic Republic of the)Congo (the)Cook Islands (the)Costa RicaCÙte d’IvoireCroatiaCubaCuraÁaoCyprusCzech Republic (the)DenmarkDjiboutiDominicaDominican Republic (the)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (the) [Malvinas]Faroe Islands (the)FijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern Territories (the)GabonGambia (the)GeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (the)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea (the Democratic People’s Republic of)Korea (the Republic of)KuwaitKyrgyzstanLao People’s Democratic Republic (the)LatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia (the former Yugoslav Republic of)MadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall Islands (the)MartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Midway IslandsMoldova (the Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands (the)New CaledoniaNew ZealandNicaraguaNiger (the)NigeriaNiueNorfolk IslandNorthern Mariana Islands (the)NorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippines (the)PitcairnPolandPortugalPuerto RicoQatarRÈunionRomaniaRussian Federation (the)RwandaSaint BarthÈlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSouthern RhodesiaSpainSri LankaSudan (the)SurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan (Province of China)TajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos Islands (the)TuvaluUgandaUkraineUnited Arab Emirates (the)United KingdomUnited StatesUnited States Minor Outlying Islands (the)Upper VoltaUruguayUzbekistanVanuatuVenezuela (Bolivarian Republic of)Viet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Additional Info How did you hear about us? Search Engine Radio Yellow Pages Twitter Facebook Instagram TV Physician Friend / Family Member Other Other 40% Complete (success) Which of the following symptoms apply at this time? Please check EACH symptom. For symptoms that do not apply, please mark NONE. Decline in your feeling of general well-being (general state of health, subjective feeling) None Mild Moderate Severe Extremely Severe Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache) None Mild Moderate Severe Extremely Severe Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain) None Mild Moderate Severe Extremely Severe Sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness) None Mild Moderate Severe Extremely Severe Increased need for sleep, often feeling tired None Mild Moderate Severe Extremely Severe Irritability (feeling aggressive, easily upset about little things, moody) None Mild Moderate Severe Extremely Severe Nervousness (inner tension, restlessness, feeling fidgety) None Mild Moderate Severe Extremely Severe Anxiety (feeling panicky) None Mild Moderate Severe Extremely Severe Physical exhaustion / lacking vitality (general decrease in performance, reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, of having to force oneself to undertake activities) None Mild Moderate Severe Extremely Severe Decrease in muscular strength (feeling of weakness) None Mild Moderate Severe Extremely Severe 40% Complete (success) Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use) None Mild Moderate Severe Extremely Severe Feeling that you have passed your peak None Mild Moderate Severe Extremely Severe Feeling burnt out, having hit rock-bottom None Mild Moderate Severe Extremely Severe Decrease in beard growth None Mild Moderate Severe Extremely Severe Decrease in ability/frequency to perform sexually None Mild Moderate Severe Extremely Severe Decrease in the number of morning erections None Mild Moderate Severe Extremely Severe Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse) None Mild Moderate Severe Extremely Severe Please share any additional comments about your symptoms you would like to address. Please list any prior hormone therapy? Recent PSA: Recent Digital Rectal Exam (Date) What were the results? Normal Abnormal History of Prostate problems or Biopsy. If so, please provide details.
