PART TWO: Required Initial Evaluation
Last Name_____________....Authorization Number:__________....Physician______________History: MEN ONLY
Last name, first name, birth date
Phone number and identification number (chart or Social security)
Age of Onset of Diabetes: History of effects of disease
Complications of diabetes: including obesity, hypertension, heart disease
All Medications used: past and present, indications
Other medical and surgical conditions
Smoking and alcohol history:
Physical Examination
Height, weight, waist, hip and wrist measurements in inches
Blood pressure
Prostate examination
Laboratory Tests
CBC
SMA-12
Lipids: Total cholesterol, LDL-C, HDL-C, triglycerides, ratio
Hemoglobin A1C
Fasting insulin: off oral agents for 2 days
C-reactive Protein
Homocysteine
C-peptides (if available)
Total Testosterone
Free testosterone
Sex Hormone Binding Globulin (SHBG)
Estradiol (total)
FSH and LH
Thyroid: TSH, T3 free, T4 free
DHEA-sulfate
Prostate Specific Antigen
All non-insulin dependent diabetic men need to have a fasting, two-hour glucose test with insulin measurements at 0, 1, and 2 hours. The purpose of this test to to determine the 'insulin resistance' before and after testosterone treatment. As their blood glucose drops, they will be weaned off oral hypogylcemic agents. Insulin dependent diabetic men are followed for the decrease in amount of insulin needed to control their blood glucose. The end-point of the study is the change in hemoglobin A1C after three months of treatment.
Overview:
TO PARTICIPATE IN THE Men's TESTOSTERONE in DIABETES STUDY!
PART I: Read through the following Introduction and Selection Process
PART II: Print out the History, Physical and Screening laboratory tests for your physician to complete.
PART III: Have your physician complete the REQUEST TO PARTICIPATE
PART IV: Sign the informed consent, have your doctor witness it, and mail MEDICAL HISTORY and physical exam (including prostate), PARTS II, III, and IV
back to me. Fax questions to me at (248)644-0066
PART V: I will mail back an authorization number for this individual at this doctor location only.