Before HRT Checklist (Male)
Place an "X" for EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE.
Rows
Choose One
1. Decline in your feeling of general wellbeing (general state of health, subjective feeling)
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
2. Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache)
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
3. Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain)
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
4. Sleep problems (difficulty in falling asleep, difficulty in sleeping through the night,
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
waking up early and feeling tired, poor sleep, sleeplessness)
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
s. Increased need for sleep, often feeling tired
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
6. Irritability (feeling aggressive, easily upset about little things, moody)
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
7. Nervousness (inner tension,restlessness, feeling fidgety)
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
8. Anxiety (feeling panicky)
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (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 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
10. Decrease in muscular strength (feeling of weakness)
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (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 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
12. Feeling that you have passed your peak
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
13. Feeling burnt out, having hit rock-bottom
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
14, Decreue in beard growth
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
15. Decrease in ability/frequency to perform sexually
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
16. Decrease in the number of morning erections
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
17. Decruse in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
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 day per week (Low)
2·3 days per week (Average)
More than 3 days per week (High)
Please list any prior hormonal therapy?
Recent PSA
Recent Digital Rectal Exam: Date
Recent Digital Rectal Exam: Normal / Abnormal
History of prostate problem, or biopsy, if so, please provide details
Submit
Should be Empty: