Testing Request Medical history Have you ever been diagnosed with prostate cancer? YesNo Did you undergo treatment for prostate cancer? YesNo Do you have kidney disease? YesNo Have you ever been diagnosed with breast cancer? YesNo Do you have uncontrolled or poorly controlled heart failure? YesNo Are you currently on testosterone replacement therapy (TRT) or have recently been on TRT within past 3 months? YesNo Are you currently or have you recently been on another anabolic steroid like testosterone? YesNo Are you currently, or within the past 60 days, taking opioid pain medications (like hydrocodone, oxycodone, buprenorphine, morphine, etc.) OR glucocorticoid type meds (like prednisone, cortisone, dexamethasone, etc) on a frequent, long term basis. YesNo Are you having any of the following signs and symptoms consistent with low testosterone. Check each below if present: FatigueWeight gainLoss of muscle or strengthErectile dysfunctionPoor focusLow sex driveLoss of drive/motivationLow or “blah mood”Increased irritabilityHot flushes/sweatsLess physical staminaLess hair growth Consent for testing My signature below indicates my consent for blood testing in order to assess my overall health and any symptoms that I have reported above. This test will be used by National TRT Clinics in order to access need for Low T treatment or other interventions as indicated by the lab results. I understand that I will have a blood testing appointment set up at the nearest contracted lab facility in my area, as indicated by my address above. For accurate testosterone testing it's important to avoid testing when your sick, or have just recovered from being ill within the past week, OR did not have a typical night sleep the night before. For example, testosterone testing is not recommended when "hungover" from the night prior or having only slept a few hours. This will often result in significantly lower testosterone levels Sign name below
