HRT Male - Kucine

HRT Questionaire

(Hormone Replacement Therapy - Male)
Date

MonthDayYear
Today's Date
Date of Birth*

MonthDayYear
Date of Birth
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Place an “X” for EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE.
1. Decline in your feeling of general well-being (general state of health, subjective feeling)*

1

2

3

4

5

1 is None, 5 is Extremely Severe
2. Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache)*

1

2

3

4

5

1 is None, 5 is Extremely Severe
3. Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain)*

1

2

3

4

5

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

1

2

3

4

5

1 is None, 5 is Extremely Severe
5. Increased need for sleep, often feeling tired*

1

2

3

4

5

1 is None, 5 is Extremely Severe
6. Irritability (feeling aggressive, easily upset about little things, moody)*

1

2

3

4

5

1 is None, 5 is Extremely Severe
7. Nervousness (inner tension, restlessness, feeling fidgety)*

1

2

3

4

5

1 is None, 5 is Extremely Severe
8. Anxiety (feeling panicky)*

1

2

3

4

5

1 is None, 5 is Extremely Severe
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)*

1

2

3

4

5

1 is None, 5 is Extremely Severe
10. Decrease in muscular strength (feeling of weakness)*

1

2

3

4

5

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

1

2

3

4

5

1 is None, 5 is Extremely Severe
12. Feeling that you have passed your peak *

1

2

3

4

5

1 is None, 5 is Extremely Severe
13. Feeling burnt out, having hit rock-bottom*

1

2

3

4

5

1 is None, 5 is Extremely Severe
14. Decrease in beard growth *

1

2

3

4

5

1 is None, 5 is Extremely Severe
15. Decrease in ability/frequency to perform sexually*

1

2

3

4

5

1 is None, 5 is Extremely Severe
16. Decrease in the number of morning erections *

1

2

3

4

5

1 is None, 5 is Extremely Severe
17. Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)*

1

2

3

4

5

1 is None, 5 is Extremely Severe
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 day per week (Low)2-3 days per week (Average)More than 3 days per week (High)
Please list any prior hormone therapy?
Recent PSA
Recent Digital Rectal Exam (Date):

MonthDayYear
Date
Results of Digital Rectal Exam*

NormalAbnormal
History of Prostate problems or Biopsy. If so, please provide details.
FOR OFFICE USE ONLY
Chart ID
DOB
Appointment Date
Should be Empty:

HRT Questionaire

Place an “X” for EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE.

FOR OFFICE USE ONLY