Male Hormone Questionnaire Name* First Last PhoneEmail SymptomsDecline in general well being (general state of health)*NeverMildModerateSevereSleep problems (difficulty falling; staying asleep; waking up tired)*NeverMildModerateSevereIncreased need for sleep (feel tired often)*NeverMildModerateSevereExhaustion/lacking vitality (decreased performance & activity; lack of interest; motivation)*NeverMildModerateSevereDeclining Mental Ability/Focus/Concentration*NeverMildModerateSevereFeeling you have passed your peak*NeverMildModerateSevereFeeling burned out/hit rock bottom*NeverMildModerateSevereDecreased desire/libido*NeverMildModerateSevereDecreased ability to perform sexually*NeverMildModerateSevereInfrequent or Absent Ejaculations*NeverMildModerateSevereNo Results from E.D. Medications*NeverMildModerateSevereIrritability (aggressive; easily upset; moody)*NeverMildModerateSevereNervousness (inner tension; restlessness)*NeverMildModerateSevereAnxiety (feeling panicky)*NeverMildModerateSevereDepressed mood (feeling down; sad; lack of drive; nothing of any use)*NeverMildModerateSevereJoint pain/muscle ache (lower back; joint; limb pain)*NeverMildModerateSevereExcessive Sweating (sudden episodes; hot flashes)*NeverMildModerateSevereDecreased muscle strength*NeverMildModerateSevereBreast Development*NeverMildModerateSevereShrinking Testicles*NeverMildModerateSevereNew Migraine Headaches*NeverMildModerateSevereWeight Gain/Belly Fat/Inability to Lose Weight*NeverMildModerateSevereRapid Hair Loss*NeverMildModerateSevereDecrease in beard growth*NeverMildModerateSevereDry/wrinkled skin/brittle nails*NeverMildModerateSevereCold all the time/cold hands/cold feet*NeverMildModerateSevereChronic constipation*NeverMildModerateSevereFamily HistoryHeart Disease*YesNoDiabetes*YesNoOsteoporosis*YesNoAlzheimer’s Disease*YesNo
