HRT Male AMS Checklist

HRT Male AMS Checklist

Mark EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE.
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1. Decline in your feeling of general well-being (general state of health, subjective feeling)*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
2. Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache)*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
3. Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain)*

None -1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
4. Sleep problems (difficulty in falling asleep difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
5. Increased need for sleep, often feeling tired*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
6. Irritability (feeling aggressive, easily upset about little things, moody)*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
7. Nervousness (inner tension, restlessness, feeling fidgety)*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
8. Anxiety (feeling panicky)*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
9. Physical exhaustion / lacking vitality (general decrease in performance, reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, of having to force oneself to undertake activities)*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
10. Decrease in muscular strength (feeling of weakness)*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
11. Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use)*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
12. Feeling that you have passed your peak*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
13. Feeling burnt out, having hit rock-bottom*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
14. Decrease in beard growth*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
15. Decrease in ability/frequency to perform sexually*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
16. Decrease in the number of morning erections*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
17. Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)*

None - 1Mild - 2Moderate - 3Severe - 4Extremely Severe - 5
Please share any additional comments about your symptoms you would like to address.
Do you have cold hands and feet?*

YesNo
Do you have daily bowel movements?*

YesNo
Do you have gas,bloating or abdominal pain after eating?*

YesNo
Please select your WEEKLY Activity Level based on this criteria ->Physical activity that accelerates heart rate/ Breathlessness)*

0-1 days per week (Low)2-3 days per week (Average)More than 3 days per week (High)
Please list any prior hormone therapy? (Write none if not applicable)*
Recent PSA:

MonthDayYear
Date
Recent Digital Rectal Exam (Date):

MonthDayYear
Date
Normal/Abnormal (Results for Recent PSA/Digital Rectal Exam)
History of Prostate problems or Biopsy. If so, please provide details (Write none if not applicable)*
Most recent weight*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date*

MonthDayYear
Date
Should be Empty: