Male Hormone Questionnaire

Male Hormone Questionnaire
Name*

First NameLast Name
Date Completed*

MonthDayYear
Date
Testosterone Deficiency
Please check all that apply.

Fatigue, low energyDepressed moodIrritability, angerWeight gain (body fat )Joint painLoss of fitnessAnxiety or nervousnessDecreasing memory, difficulty concentratingDecreased sex driveErectile dysfunctionDecreased intensity of orgasmsLoss of fitness abilityOsteoporosis/osteopeniaDecreased job performanceFeelings of being overwhelmedDecline in physical abilitiesElevated cholesterol
Therapeutic Benefits of testosterone replacement include heart protection against coronary artery disease, lowering cholesterol, addressing high blood pressure, stress resiliency, improved insulin sensitivity, improved cognitive function, improved muscle mass, improved stamina, improvements in sexual function, and improvements with congestive heart failure.

Causes of deficiency include aging, stress, toxic exposures, endocrine disruptors, nutrient deficiencies, low gonadotropin levels, elevated prolactin level, chronic kidney failure, hypothyroid, several medications, diabetes, low cholesterol diet, statin therapy, vegetarian/vegan diet, infections, trauma, alcohol abuse, and elevated scrotal temperature exposure.
Testosterone Excess
Please check all that apply.

Aggressive behaviorGynecomastia ( enlarged breasts)Prostate enlargementHair lossAcneMood swingsTesticular shrinkagePoor sleepElevation of hemoglobin and hematocrit
Contraindication to testosterone replacement includes prostate cancer, breast cancer, prolactinoma, unexplained rise of the PSA, severe prostate enlargement, severe untreated sleep apnea.
Estrogen Excess
Please check all that apply.

Gynecomastia ( enlarged breast tissue)Decreased libidoErectile dysfunctionProstate enlargementAbdominal obesity
Causes include liver disease, zinc deficiency, excess visceral fat, excessive alcohol consumption, exposure to xenoestrogens, high-dose testosterone replacement, medications.

Estrogen is important in men and helps maintain memory, bone density, and lipid metabolism. Deficiency can result in osteoporosis, cognitive decline, and dyslipidemia ( abnormal cholesterol profile).
Should be Empty:

Male Hormone Questionnaire

Testosterone Deficiency

Testosterone Excess

Estrogen Excess