Form
Male Symptom Check List
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Type a question
None
Mild
Moderate
Severe
Extremely Severe
Fatigue
Decline in general motivation/interest
Decrease in libido/sexual desire
Difficulty maintaining an erection
Decrease in morning erections
Sleep problems
Irritability
Nervousness/anxiety
Feeling burnt out
Joint pain/muscle aches
Decreased strength/stamina
Increased sweating (often at night)
Brain fog
Depressed mood
Decreased beard growth
Hair loss
Cold hands/feet
Signature
Date
*
-
Month
-
Day
Year
Date
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