PRESCRIPTION / Rx

Dr. _______________________________       Date: ____ / ____ / ______
Qualification: _____________________       Reg. No.: __________________
Clinic/Hospital: _____________________________________________________

Patient name: ______________________       Age/Sex: ______ / M
Address: _____________________________________________________________
Weight: ______ kg     Allergies: ______________________________________

Diagnosis:
□ Confirmed male hypogonadism
□ Primary / secondary / under evaluation
Relevant reports reviewed:
□ 2 separate early-morning total testosterone results
□ LH, FSH, prolactin     □ CBC/hematocrit
□ PSA and prostate assessment where clinically appropriate
□ LFT, lipid profile, glucose/HbA1c as indicated

Rx

1. Testosterone formulation: _________________________________________
   Strength/form: ____________________________________________________
   Route: ____________________________________________________________
   Directions: Use only as specifically explained by the prescriber.
   Quantity: ______________________

2. [Other medicine only if clinically indicated]
   ___________________________________________________________________
   Directions: _______________________________________________________

Advice:
- Do not self-inject, share, or alter the dose/interval.
- Report acne, breast tenderness, leg swelling, breathlessness,
  mood changes, severe headache, urinary symptoms, or sleep-apnoea
  worsening.
- Testosterone can suppress sperm production. Discuss fertility before
  starting treatment.
- Follow-up with CBC/hematocrit, testosterone level, symptom review and
  prostate monitoring where relevant, as advised.

Review after: ______________________

Doctor’s signature and stamp
____________________________________

• Symptoms and medical history, including fertility plans
• Two early-morning total testosterone reports
• LH, FSH, prolactin, SHBG/free testosterone if indicated
• CBC with hematocrit, PSA/prostate assessment when appropriate
• Blood pressure, glucose/HbA1c, lipid profile, liver tests
• Review for contraindications such as prostate or breast cancer, unexplained high PSA, or high hematocrit

TRT Consultation / Treatment Plan Template

                     TESTOSTERONE THERAPY (TRT) REVIEW

Clinic/Hospital: _________________________________________________
Consulting doctor: _______________________________________________
Speciality:  □ Endocrinology  □ Urology  □ Andrology
Date: ____ / ____ / ______

PATIENT DETAILS
Name: ____________________________________________________________
Age: ______ years        Sex: ______        UHID/OPD No.: __________
Phone: ___________________________________________________________
Known allergies: __________________________________________________

CLINICAL INDICATION
Symptoms present:
□ Low libido      □ Erectile dysfunction      □ Fatigue
□ Reduced morning erections   □ Low mood       □ Reduced muscle mass
□ Low bone density/fracture   □ Other: ___________________________

Duration of symptoms: ____________________________________________
Past medical/surgical history: ____________________________________
Current medicines/supplements: ____________________________________
Fertility plans now or in future: □ Yes  □ No  □ Unsure

DIAGNOSTIC ASSESSMENT
Two early-morning fasting total testosterone values:
1. Date: __________  Result: __________  Unit: _________________
2. Date: __________  Result: __________  Unit: _________________

Supporting investigations:
□ LH / FSH              □ Prolactin           □ SHBG/free testosterone
□ CBC and hematocrit    □ PSA, if appropriate
□ Liver function        □ Lipid profile       □ HbA1c/glucose
□ Blood pressure        □ Sleep-apnoea screening
□ Other: ________________________________________________________

ASSESSMENT
□ Confirmed hypogonadism
□ Primary hypogonadism
□ Secondary hypogonadism
□ Functional/reversible cause being addressed
□ Further evaluation needed before considering TRT

SAFETY SCREEN
□ Fertility counselling completed
□ No known prostate/breast malignancy
□ Hematocrit reviewed
□ PSA/prostate assessment reviewed when clinically appropriate
□ Cardiovascular history reviewed
□ Sleep apnoea reviewed
□ Contraindications/precautions discussed

CLINICIAN-SELECTED TREATMENT PLAN
Testosterone product/formulation: __________________________________
Strength and route: ________________________________________________
Dose and schedule: ________________________________________________
Duration / review date: ____________________________________________

MONITORING PLAN
□ Clinical symptom response
□ Testosterone level
□ CBC / hematocrit
□ PSA/prostate review where indicated
□ Blood pressure, metabolic and adverse-effect review
Next review date: ____ / ____ / ______

COUNSELLING DOCUMENTED
□ Do not self-adjust or share medication
□ May reduce sperm production and affect fertility
□ Possible acne, oily skin, mood changes, breast tenderness
□ Report leg swelling, breathing difficulty, severe headache,
  urinary symptoms, or worsening sleep apnoea promptly

Clinician notes:
__________________________________________________________________
__________________________________________________________________