Hormone Health · Before Your Visit

Hormone Therapy Screening Questionnaire

The same questions your provider asks at a first hormone visit — symptoms, history and goals — in a click-and-go format. It takes about five minutes, your answers stay on this page until you choose to book, and your provider reviews them before your consultation.

Question 1 of 8

Are you male or female?

Hormone therapy is different for women and men, so the questions that follow depend on your answer.

Are you a new or existing patient?

Existing patients skip the questionnaire.

Current symptoms

Select everything that applies — there are no wrong answers.

What symptoms are you currently experiencing? Select all that apply.
How much are these symptoms affecting your daily life?

Menstrual & reproductive history

When was your last menstrual period?
Are your menstrual periods currently regular?
Have you gone at least 12 consecutive months without a menstrual period?
Have you experienced vaginal bleeding or spotting after going 12 months without a period?
Is there any possibility that you are currently pregnant?
Are you currently trying to become pregnant?
Are you currently breastfeeding?

Surgical & gynecological history

Do you still have your uterus?
Have you had a hysterectomy?
Do you still have your ovaries?
Have you ever been diagnosed with any of the following? Select all that apply.

Cancer & breast health

Have you ever been diagnosed with breast cancer?
Have you ever been diagnosed with any of the following cancers? Select all that apply.
Have you ever had an abnormal mammogram?
Have you ever had a breast biopsy?
Are you currently experiencing any of the following? Select all that apply.
When was your last mammogram?
Do you have a family history of any of the following cancers? Select all that apply.
Do you or a family member have a known BRCA1, BRCA2, or other hereditary cancer-related genetic mutation?

Blood clot & cardiovascular history

Have you ever had a blood clot in your leg (DVT)?
Have you ever had a blood clot in your lung (pulmonary embolism/PE)?
Have you ever had a stroke or transient ischemic attack (TIA/“mini-stroke”)?
Have you ever had a heart attack or been diagnosed with coronary artery disease?
Have you ever been diagnosed with a blood-clotting disorder?
Does anyone in your immediate family have a history of recurrent or unexplained blood clots?
Do you currently smoke or use nicotine products?
Have you been diagnosed with high blood pressure?
Have you been diagnosed with high cholesterol?
Do you have diabetes?

Migraine history

Do you experience migraine headaches?
If yes, do you experience an aura before or during your migraines, such as flashing lights, blind spots, visual changes, numbness, or tingling?

Other medical history

Have you ever been diagnosed with liver disease?
Have you ever been diagnosed with gallstones or gallbladder disease?
Do you have kidney disease?
Do you have thyroid disease?
Do you have a seizure disorder?
Have you been diagnosed with lupus or another autoimmune disorder?
Have you been diagnosed with osteoporosis or osteopenia?
Have you ever had a fracture from a minor fall or injury?
Are you currently experiencing unexplained vaginal bleeding?

Current & previous hormone treatment

Have you ever used hormone replacement therapy (HRT)?
Have you ever taken or used any of the following? Select all that apply.
If you previously used HRT, did you stop because of side effects?
Are you currently receiving hormones from another provider or clinic?
Are you currently taking birth control or another hormonal medication?

Testosterone-specific screening

Are you experiencing decreased sexual desire or libido?
If yes, is the decrease in sexual desire causing you personal distress or affecting your relationship or quality of life?
Are you currently experiencing any of the following? Select all that apply.

Medications & primary care

Are you currently taking prescription medications?
Are you currently taking vitamins, supplements, herbal products, or over-the-counter medications?
Does your primary care provider know that you are considering or currently receiving hormone replacement therapy?
Are you currently under the care of any specialists?

Treatment goals

What are your primary goals for hormone therapy? Select all that apply.
Is there anything else about your medical history, symptoms, medications, or health that you believe your provider should know before considering hormone therapy?

Current symptoms

Select everything that applies — there are no wrong answers.

What symptoms are you currently experiencing? Select all that apply.
How long have you been experiencing these symptoms?
How much are these symptoms affecting your daily life?

Sexual health

Have you noticed a decrease in your sex drive?
Are you experiencing difficulty obtaining an erection?
Are you experiencing difficulty maintaining an erection?
Have you noticed fewer morning or spontaneous erections?
Have you noticed a change in your sexual performance or satisfaction?

Fertility & reproductive health

Testosterone therapy can affect fertility, so we ask about this up front.

Do you currently have biological children?
Do you want to have biological children in the future?
Are you currently trying to conceive with a partner?
Have you ever experienced infertility or difficulty conceiving?
Have you ever had a vasectomy?
Have you noticed any decrease in testicular size?
Have you ever had an injury, infection, surgery, or other medical problem involving your testicles?

Prostate & urinary health

Have you ever been diagnosed with prostate cancer?
Have you ever had an abnormal PSA (prostate-specific antigen) test?
Have you ever had an abnormal prostate examination or prostate biopsy?
Have you ever been diagnosed with an enlarged prostate (BPH)?
Are you experiencing any of the following urinary symptoms? Select all that apply.
Do you have a father, brother, or son who has been diagnosed with prostate cancer?

Breast health

Have you ever been diagnosed with male breast cancer?
Are you currently experiencing any of the following? Select all that apply.

Cardiovascular & blood clot history

Have you ever had a heart attack?
Have you ever had a stroke or TIA (“mini-stroke”)?
Have you ever been diagnosed with coronary artery disease or another significant heart condition?
Have you ever been diagnosed with heart failure?
Have you ever had a blood clot in your leg (DVT)?
Have you ever had a blood clot in your lung (pulmonary embolism/PE)?
Have you ever been diagnosed with a blood-clotting disorder?
Have you been diagnosed with high blood pressure?
Have you been diagnosed with high cholesterol or high triglycerides?
Do you currently smoke or use nicotine products?

Sleep apnea & sleep

Have you been diagnosed with sleep apnea?
If you have sleep apnea, are you currently using your prescribed CPAP/BiPAP or other treatment?
Has anyone told you that you snore loudly or stop breathing/gasp for air while sleeping?
Do you frequently experience excessive daytime sleepiness despite getting adequate sleep?

Blood & hematologic history

Have you ever been told that your red blood cell count, hemoglobin, or hematocrit was too high?
Have you ever been diagnosed with polycythemia or erythrocytosis?
Have you ever required therapeutic blood donation/phlebotomy because your blood count was too high?

Metabolic & other medical conditions

Do you have diabetes?
Have you ever been diagnosed with liver disease?
Have you ever been diagnosed with kidney disease?
Do you have thyroid disease?
Have you ever had a significant head injury or traumatic brain injury?
Have you ever been diagnosed with a pituitary disorder or pituitary tumor?

Previous testosterone & hormone use

Have you ever used testosterone replacement therapy?
Are you currently receiving testosterone from another provider, clinic, or online service?
What forms of testosterone have you previously used? Select all that apply.
Have you ever used anabolic steroids or performance-enhancing hormones for bodybuilding, athletic performance, or another nonmedical purpose?
Have you ever used any of the following? Select all that apply.
If you previously used testosterone or another hormone treatment, did you experience side effects?

Current medications & care

Are you currently taking prescription medications?
Are you taking vitamins, supplements, herbal products, or over-the-counter medications?
Are you currently taking medication for erectile dysfunction, such as sildenafil (Viagra) or tadalafil (Cialis)?
Does your primary care provider know that you are considering or currently receiving testosterone replacement therapy?
Are you currently under the care of a urologist, endocrinologist, cardiologist, or another specialist?

Treatment goals

What are your primary goals for hormone therapy? Select all that apply.
Is maintaining your fertility important to you?
Is there anything else about your medical history, symptoms, medications, or health that your provider should know before considering testosterone therapy?

This questionnaire gathers information for your provider — it does not decide eligibility. Decisions about hormone therapy, including labs and any screening, are made together with your provider at your consultation. Your answers stay in your browser and are only sent to the clinic if you choose to book.

What Happens Next

From Questionnaire to Treatment

1

Complete the Questionnaire

About five minutes of click-and-go questions — the same ones your provider asks at a first visit.

2

Book Your Consultation

Request your hormone consultation — your answers go with it so your provider can prepare.

3

Meet Your Provider

A confidential consultation with Latrina — labs when indicated, then a plan built around you.