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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.
Nota: Este formulario también está disponible en español. Seleccione su preferencia de idioma en el menú desplegable ubicado en la parte superior derecha de este formulario para cambiar a la versión en español.
1. Decline in your feeling of general well-being (general state of health, subjective feeling)
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
2. Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache)
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
3. Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain)
*
None -1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
4. Sleep problems (difficulty in falling asleep difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
5. Increased need for sleep, often feeling tired
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
6. Irritability (feeling aggressive, easily upset about little things, moody)
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
7. Nervousness (inner tension, restlessness, feeling fidgety)
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
8. Anxiety (feeling panicky)
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely 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 - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
10. Decrease in muscular strength (feeling of weakness)
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely 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 - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
12. Feeling that you have passed your peak
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
13. Feeling burnt out, having hit rock-bottom
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
14. Decrease in beard growth
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
15. Decrease in ability/frequency to perform sexually
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
16. Decrease in the number of morning erections
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
17. Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)
*
None - 1
Mild - 2
Moderate - 3
Severe - 4
Extremely Severe - 5
Please share any additional comments about your symptoms you would like to address.
Do you have cold hands and feet?
*
Yes
No
Do you have daily bowel movements?
*
Yes
No
Do you have gas,bloating or abdominal pain after eating?
*
Yes
No
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:
-
Month
-
Day
Year
Date
Recent Digital Rectal Exam (Date):
-
Month
-
Day
Year
Date
Normal/Abnormal (Results for Recent PSA/Digital Rectal Exam)
Please Select
Normal
Abnormal
History of Prostate problems or Biopsy. If so, please provide details (Write none if not applicable)
*
Most recent weight
*
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: