Symptom Questionnaire

Male Health Form

How do you identify?

Male

Female

Prefer not to say

First Name

Last Name

Date / Time

Are you currently on testosterone replacement therapy (TRT)?

Yes

Have you noticed changes in libido, stamina, or muscle mass?

Yes

Do you have a history of thyroid or metabolic issues?

Yes

Are you currently on testosterone replacement therapy (TRT)?

Yes

Have you noticed changes in libido, stamina, or muscle mass?

Yes

Do you have a history of thyroid or metabolic issues?

Yes

Are you currently on hormone replacement therapy (HRT)?

Yes

Have you experienced changes in mood, weight, or menstrual cycles?

Yes

Do you have a history of thyroid issues or PCOS?

Yes

How would you rate your energy levels?

Low

Moderate

High

Have you experienced unexplained weight gain or loss?

Yes

What are your top 3 health concerns right now?

Message

Your trusted hormone replacement therapy clinic, where personalized care and evidence-based wellness come together.

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33 W. Main St, Ste 203 Georgetown, MA 01833
support@veyraewellness.com
+1-(978) 403-6982
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VEYRAE Wellness

Symptom Questionnaire

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