HYPOGONADISM

HYPOGONADISM

PATIENT QUESTIONNAIRE (Version 06.08.23)
Name*

First NameLast Name
Date of birth:*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
1. Are you currently receiving treatment for Hypogonadism (Low Testosterone)*

YesNoDon't know
2. What treatment are you currently administering?*

Testosterone injectionsTestosterone gelTestosterone pelletsIntranasal testosteroneTestosterone pillsClomiphene Citrate (Clomid)HCGAnastrazoleTamoxifen
3. For how many years have you been treated for hypogonadism?*
4. How satisfied are you with your current treatment?*

Very dissatisfiedSomewhat dissatisfiedNeither satisfied nor dissatisfiedSomewhat satisfiedVery satisfied
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...
1. How many times did you engage in sexual activities?*
2. How many times did you initiate sexual activities? *
3. How many times did you achieve an erection when you wanted to engage in sexual activities? *
4. Did you have sexual thoughts or fantasies?*

NeverRarelySometimesOftenAlways
5. Did you feel sexual desire?*

NeverRarelySometimesOftenAlways
6. Did you have difficulty achieving erections when you wanted to?*

NeverRarelySometimesOftenAlways
7. Did you have difficulty maintaining erection as long as you wanted to?*

NeverRarelySometimesOftenAlways
8. Did you have difficulty ejaculating (coming)?*

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

Over the past 7 days...
9. Did you have difficulty ejaculating (coming)?*

NeverRarelySometimesOftenAlways
10.How tired were you?*

Not at allA littleModeratelyQuite a bitExtremely
11.Did you have low energy?*

Not at allA littleModeratelyQuite a bitExtremely
12.How much difficulty did you have getting enough sleep at night?*

No difficultyA little difficultyModerate difficultyA great deal of difficultyExtreme difficulty
13.How often did you accidently doze off during the day?*

NeverRarelySometimesOftenAlways
14.How forgetful were you?*

Not at allA littleQuite a bitExtremely
15.How well were you able to focus your attention on tasks?*

Not at allA littleQuite a bitExtremely
16.Did you feel sad?*

Not at allA littleQuite a bitExtremely
17.Did you feel irritable?*

Not at allA littleQuite a bitExtremely
18.Did you feel motivated about things you needed to do?*

Not at allA littleQuite a bitExtremely
Patient or Representative Signature*

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