Male Pre-HRT Questionnaire

Please fill out prior to purchase

Name*

First NameLast Name

Date

Phone Number*

Area CodePhone Number

Email*

example@example.com

Select EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE.

Rows	None	Mild	Moderate	Severe	Extremely Severe
1. Decline in your feeling of general well-being (General state of health, subjective feeling)
2. Joint pain and general muscle ache (lower back pain, joint pain, general back ache)
3. Excessive Sweating (Unexpected/sudden episodes of sweating, hot flashes)
4. Sleep Problems (Difficulty falling, or staying asleep, feeling tired upon waking)
5. Increased need for sleep, often feeling tired.
6. Irritability (Feeling aggressive, easily upset, moody)
7. Nervousness (inner tension, restlessness, feeling fidgety)
8. Anxiety (feeling panicky)
9. Physical Exhaustion / lacking vitality (general decrease in performance, reduced activity, lack of interest in leisure activities, feeling of getting less done, achieving less, having to force oneself to undertake activities)
10. Decreased muscular strength (Feeling of weakness)
11. Depressive mood (Feeling down, sadness, lack of drive, mood swings)
12. Feeling that you've passed your peak
13. Feeling burnt out
14. Decrease in beard growth
15. Decrease in ability/frequency to perform sex
16. Decrease in number of morning erections
17. Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)

YesNo

0-1 Day per week2-3 Days per weeekmore than 3 days per week

YesNo

Please discuss any history of prostate problems or additional symptoms you may be feeling with the practitioner at the time of your appointment.