SummitRxPharmacy.com | P: 816-524-8444 | 1405 NE Douglas | Lee's Summit, MO

MALE HRT SYMPTOM UPDATE

First Name *

Last Name *

Date of Birth * +

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(Home number if no mobile number) *

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Have there been any changes in any of your medications in the past year? If so, please list them below: *

Height *

Weight *

Please check all symptoms below that apply (this is very important to the evaluation process):

Symptoms of low Progesterone?

Symptoms of low Testosterone?

Other symptoms?

Have any symptoms become more frequent/bothersome in the past few months?

Signing here gives the pharmacist permission to make dosing change suggestions to your physician. *

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Acne	Anxiety/Irritability
Weight Gain	Mood Swings
Food Cravings	Joint Pain
Low Sex Drive	Depression
Fuzzy Thinking	Low Energy
Insomnia	Headaches (# per week) Headaches (# per week)