Health Assessment For Men
Male Symptom Questionnaire
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Email
example@example.com
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 "never" .
Sweating (night sweats or excessive sweating)
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early )
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Increased need for sleep or falls asleep easily after a meal
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Depressive mood (Feeling down, sad, lack of drive)
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Irritability (mood swings, feeling aggressive, angers easily)
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina, or motivation )
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Sexual problems (change in sexual desire or in sexual performance)
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Bladder Problems (difficulty in urinating, increased need to urinate)
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Erectile changes (less strong erections, loss of morning erections)
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Difficulties with memory
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Problems with thinking, concentrating or reasoning
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Difficulty learning new things
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Trouble thinking of the right word to describe persons, places or things when speaking
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Increase in frequency or intensity of headaches/migraines
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Rapid hair loss or thinning
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Feel cold all the time or have cold hands and feet
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Weight gain, increased belly fat or difficulty losing weight despite diet and exercise
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Infrequent or absent ejaculations
Never
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Submit
Should be Empty: