MALE HEALTH ASSESSMENT

MALE HEALTH ASSESSMENT
Name*

First NameLast Name
Birth Date*

MonthDayYear
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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”.
Sweating (night sweats or excessive sweating)*

NoneMildModerateSevereVery severe
Sleep problems (difficulty falling asleep, sleeping throughthe night or waking up too early)*

NoneMildModerateSevereVery severe
Increased need for sleep or falls asleep easily after a meal*

NoneMildModerateSevereVery severe
Depressive mood (feeling down, sad, lack of drive)*

NoneMildModerateSevereVery severe
Irritability (mood swings, feeling aggressive, angers easily)*

NoneMildModerateSevereVery severe
Anxiety (inner restlessness, feeling panicked, feeling nervous, inner tension)*

NoneMildModerateSevereVery severe
Physical exhaustion (general decrease in muscle strength orendurance, decrease in work performance, fatigue, lack of energy,stamina or motivation)*

NoneMildModerateSevereVery severe
Sexual problems (change in sexual desire or in sexual performance)*

NoneMildModerateSevereVery severe
Bladder problems (difficulty in urinating, increased need to urinate)*

NoneMildModerateSevereVery severe
Erectile changes (weaker erections, loss of morning erections)*

NoneMildModerateSevereVery severe
Joint and muscular symptoms (joint pain or swelling,muscle weakness, poor recovery after exercise)*

NoneMildModerateSevereVery severe
Difficulties with memory*

NoneMildModerateSevereVery severe
Problems with thinking, concentrating or reasoning*

NoneMildModerateSevereVery severe
Difficulty learning new things*

NoneMildModerateSevereVery severe
Trouble thinking of the right word to describe persons, placesor things when speaking*

NoneMildModerateSevereVery severe
Increase in frequency or intensity of headaches/migraines*

NoneMildModerateSevereVery severe
Rapid hair loss or thinning*

NoneMildModerateSevereVery severe
Feel cold all the time or have cold hands or feet*

NoneMildModerateSevereVery severe
Weight gain, increased belly fat, or difficulty losing weightdespite diet and exercise*

NoneMildModerateSevereVery severe
Infrequent or absent ejaculations*

NoneMildModerateSevereVery severe
Total Score
Severity score: Mild: 1-20 / Moderate: 21-40 / Severe: 41-60 / Very severe: 61-80
Should be Empty: