15714 Huebner, Bldg. 5 San Antonio, TX Huebner Office Plaza

La Femme OBGYN

Virginia Aguilar, D.O., F.A.C.O.G.

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Men HRT Questionnaire

New Patient Hormone Replacement Therapy Questionnaire (Men)

Contact Us

Patient Information:

Patient Information:

Full Name:

Date of Birth:

Phone Number:

Preferred method of contact:

Phone Call

Text Message

Email

1. Medical History

1. Medical History

Do you have any pre-existing medical conditions? (e.g., diabetes, heart disease, thyroid disorders)

Yes

No

Please specify:

Are you currently taking any medications or supplements?

Yes

No

Please specify:

Do you have any known allergies?

Yes

No

Please specify:

Have you undergone any surgeries or major medical procedures in the past?

Yes

No

Please specify:

Do you have a history of prostate or testicular health issues?

Yes

No

Please specify:

Have you experienced any of the following conditions?

Sleep Apnea

High Blood Pressure

High Cholesterol

Depression or Anxiety

Erectile Dysfunction

Diabetes

Other (Please specify):

2. Hormonal Symptoms

2. Hormonal Symptoms

Do you experience any of the following symptoms? (Check all that apply)

Low Energy or Fatigue

Decreased Muscle Mass

Option 3

Decreased Libido (Sex Drive)

Erectile Dysfunction

Mood Swings or Irritability

Difficulty Concentrating or Memory Issues

Hair Loss

Insomnia or Poor Sleep

Other (Please specify):

How long have you been experiencing these symptoms?

3. Lifestyle and Habits

3. Lifestyle and Habits

How would you describe your typical diet?

Balanced and Healthy

Moderately Healthy

Unhealthy

Do you exercise regularly?

Yes

No

Do you smoke or use tobacco products?

Yes

No

Do you consume alcohol?

Yes

No

Frequency:

How many hours of sleep do you get on average per night?

How would you rate your stress level?

Low

Moderate

High

Have you recently noticed changes in your mental focus or motivation?

Yes

No

4. Hormone Replacement Therapy (HRT) Interest

4. Hormone Replacement Therapy (HRT) Interest

Have you received Hormone Replacement Therapy in the past?

Yes

No

Please specify when and where:

What do you hope to achieve from HRT? (Check all that apply)

Increased Energy

Improved Libido

Better Muscle Mass and Strength

Improved Mood and Mental Clarity

Weight Loss

Improved Sleep

Other (Please specify):

Do you have any concerns or questions about HRT?

5. Family Medical History

5. Family Medical History

Does anyone in your family have a history of hormone-related conditions?

Ye

No

Please specify:

Do you have a family history of prostate cancer, heart disease, or diabetes?

Yes

No

Please specify:

6. Additional Information

6. Additional Information

Is there anything else you’d like us to know about your health or symptoms?

What are your expectations from the Hormone Replacement Therapy?

7. Consent and Agreement

7. Consent and Agreement

Are you willing to undergo blood tests to evaluate your hormone levels?

Yes

No

Do you consent to discussing your health and hormone therapy options with our medical team?

Yes

No

Thank you for contacting us.
We will get back to you as soon as possible.

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La Femme OBGYN

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Home
Meet the Team
Gynecology Services
Pre-Natal Care
Weight Loss Injections
Hormone Replacement Therapy
Financing
Contact Us

CONTACT INFORMATION

Phone: (210) 492-2300

Se Habla Espanol

Email: vaguilar011305@gmail.com

Address: 15714 Huebner, Bldg. 5 San Antonio, TX Huebner Office Plaza

BUSINESS HOURS

Mon, Tue, Thu: 9:00 am - 5:00 pm
Wednesday: 8:00 am - 5:00 pm
Friday: 8:00 am - 12:00 pm
Sat - Sun: Closed

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