HYPOGONADISM

  • HYPOGONADISM

    PATIENT QUESTIONNAIRE (Version 06.08.23)
  • Date of birth:*
     - -
  • Format: (000) 000-0000.
  • 1. Are you currently receiving treatment for Hypogonadism (Low Testosterone)*
  • 2. What treatment are you currently administering?*
  • 4. How satisfied are you with your current treatment?*

  • Hypogonadism Impact of Symptoms Questionnaire Short Form (HIS-Q-SF)


    Instructions: The following questions ask about experiences that might be related to your low testosterone. When answering the questions, please select the response that best describes your experiences over the period of time specified.

    These first 8 questions ask about your sexual activities and experiences over the past 14 days. Sexual activities could include masturbation or sexual activities with a partner (including touching, oral stimulation, intercourse, or other activity).

     

    Over the past 14 days...

  • 4. Did you have sexual thoughts or fantasies?*
  • 5. Did you feel sexual desire?*
  • 6. Did you have difficulty achieving erections when you wanted to?*
  • 7. Did you have difficulty maintaining erection as long as you wanted to?*
  • 8. Did you have difficulty ejaculating (coming)?*

  • These next questions ask about other experiences over the past 7 days.

     Over the past 7 days...

  • 9. Did you have difficulty ejaculating (coming)?*
  • 10.How tired were you?*
  • 11.Did you have low energy?*
  • 12.How much difficulty did you have getting enough sleep at night?*
  • 13.How often did you accidently doze off during the day?*
  • 14.How forgetful were you?*
  • 15.How well were you able to focus your attention on tasks?*
  • 16.Did you feel sad?*
  • 17.Did you feel irritable?*
  • 18.Did you feel motivated about things you needed to do?*
  • Date*
     - -
  • Should be Empty: