Approx. Reason for Name Specialty Address Dates/Years of Visits MEDICAL BACKGROUND OF THE PERSON TREATED WITH TRT (“YOU”) Current Height: Current Weight: Do you currently suffer from any serious physical injuries, illnesses or disabilities other than those that you believe were caused by TRT? Yes _____ No _____ If yes, provide the information requested below: Physician Who Injury, Illness or Date of Onset Date of Diagnosis Diagnosed You Disability (Name and Address) For the period of time fifteen (15) years prior to your use of TRT up to the present, have you ever used tobacco (including cigarettes, cigars, pipes, and/or chewing tobacco/snuff)? Yes _____ No _____ If yes, provide the information requested for each type of tobacco ever used: Date Use Stopped Type(s) of tobacco Dates of Use Amount Used Per Blank if used (approx.) Day (approx.) Currently Use) For the period of time five (5) years prior to your treatment with TRT up to the present, did you drink alcohol? Yes _____ No _____ If yes, what was your approximate average alcohol consumption during that time: _____ approximately drinks per day, or _____ approximately drinks per week, or approximately drinks per month, or
Name Specialty Address Reason for Approx. Dates/Years of Visits MEDICAL BACKGROUND OF THE PERSON TREATED WITH TRT (“YOU”) Current Height: Current Weight: Do you currently suffer from any serious physical injuries, illnesses or disabilities other than those that you believe were caused by TRT? Yes _____ No _____ If yes, provide the information requested below: Injury, Illness or Disability Date of Onset Date of Diagnosis Physician Who Diagnosed You (Name and Address) For the period of time fifteen (15) years prior to your use of TRT up to the present, have you ever used tobacco (including cigarettes, cigars, pipes, and/or chewing tobacco/snuff)? Yes _____ No _____ If yes, provide the information requested for each type of tobacco ever used: Type(s) of tobacco used Dates of Use (approx.) Amount Used Per Day (approx.) Date Use Stopped Blank if Currently Use) For the period of time five (5) years prior to your treatment with TRT up to the present, did you drink alcohol? Yes _____ No _____ If yes, what was your approximate average alcohol consumption during that time: _____ approximately drinks per day, or _____ approximately drinks per week, or approximately drinks per month, or
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