Male Hormone Questionnaire Name* First Last PhoneEmail SymptomsDecline in general well being (general state of health)* Never Mild Moderate Severe Sleep problems (difficulty falling; staying asleep; waking up tired)* Never Mild Moderate Severe Increased need for sleep (feel tired often)* Never Mild Moderate Severe Exhaustion/lacking vitality (decreased performance & activity; lack of interest; motivation)* Never Mild Moderate Severe Declining Mental Ability/Focus/Concentration* Never Mild Moderate Severe Feeling you have passed your peak* Never Mild Moderate Severe Feeling burned out/hit rock bottom* Never Mild Moderate Severe Decreased desire/libido* Never Mild Moderate Severe Decreased ability to perform sexually* Never Mild Moderate Severe Infrequent or Absent Ejaculations* Never Mild Moderate Severe No Results from E.D. Medications* Never Mild Moderate Severe Irritability (aggressive; easily upset; moody)* Never Mild Moderate Severe Nervousness (inner tension; restlessness)* Never Mild Moderate Severe Anxiety (feeling panicky)* Never Mild Moderate Severe Depressed mood (feeling down; sad; lack of drive; nothing of any use)* Never Mild Moderate Severe Joint pain/muscle ache (lower back; joint; limb pain)* Never Mild Moderate Severe Excessive Sweating (sudden episodes; hot flashes)* Never Mild Moderate Severe Decreased muscle strength* Never Mild Moderate Severe Breast Development* Never Mild Moderate Severe Shrinking Testicles* Never Mild Moderate Severe New Migraine Headaches* Never Mild Moderate Severe Weight Gain/Belly Fat/Inability to Lose Weight* Never Mild Moderate Severe Rapid Hair Loss* Never Mild Moderate Severe Decrease in beard growth* Never Mild Moderate Severe Dry/wrinkled skin/brittle nails* Never Mild Moderate Severe Cold all the time/cold hands/cold feet* Never Mild Moderate Severe Chronic constipation* Never Mild Moderate Severe Family HistoryHeart Disease* Yes No Diabetes* Yes No Osteoporosis* Yes No Alzheimer’s Disease* Yes No
