HEALTH ASSESSMENT FOR MEN
(MALE SYMPTOM QUESTIONNAIRE)
470.655.6574
gentlegiantcarellc@gmail.com
GentleGiantCareLLC.com
600 Peachtree Parkway, Ste 104 Cumming GA, 30041
Name
*
Date of Birth
*
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Month
-
Day
Year
Phone Number
*
Email
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
MALE HEALTH ASSESSMENT
Which of the following symptoms apply to you currently (in the last 2 weeks)? Please mark the appropriate box for each symptom. For symptoms that do not currently apply or no longer apply, mark “none”.
*
None
Mild
Moderate
Severe
Very
Severe
Sweating (night sweats or increased episodes of sweating)
Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)
Increased need for sleep or falls asleep easily after a meal
Depressive mood (feeling down, sad,
lack of drive)
Irritability (mood swings, feeling aggressive, angers easily)
Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)
Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)
Sexual problems (change in sexual desire or in sexual performance)
Bladder problems (difficulty in urinating, increased
need to urinate)
Erectile changes(Less strong erections, loss of morning erections)
Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)
Difficulties with memory
Problems with thinking, concentrating or reasoning
Difficulty learning new things
Trouble thinking of the right word to describe persons, places or things when speaking
Increase in frequency or intensity of headaches or migraines
Hair loss, thinning or change in texture of hair
Feel cold all the time or have cold hands or feet
Weight gain or difficulty losing weight despite diet and exercise
Dry or wrinkled skin
Total score
SEVERITY
SCORE
Mild
1-20
Moderate
21-40
Severe
41-60
Very Severe
61-80
Submit
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HEALTH ASSESSMENT FOR MEN