MALE HEALTH ASSESSMENT QUESTIONNAIRE

MALE HEALTH ASSESSMENT QUESTIONNAIRE

Please mark the appropriate box for each symptom you may be experiencing.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear

Over the last 2 weeks, how often have you been bothered by and of the following problems?

Rows	NONE	MILD	MODERATE	SEVERE	VERY SEVERE
1. Physical Exhaustion (fatigue, lack of energy, stamina or motivation)
2. Sleep Problems (difficulty falling asleep or sleeping through the night)
3. Irritability (mood swings, feeling aggressive, angers easily)
4. Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous)
5. Decline in drive or interest (loss of “zest for life,” feeling down or sad)
6. Joint and muscular symptoms (poor recovery after workout, inability to add muscle, joint pain, muscle weakness)
7. Difficulties with memory (concentration, finding the right word, or retaining information)
8. Sexual Desire or Performance (reduced or diminished)
9. Erectile changes (weaker erections, loss of morning erections)
10. Ejaculations (infrequent or absent)
11. Sweating (night sweats or increased episodes of sweating)
12. Hair loss, rapid or thinning
13. Feeling cold all the time, having cold hands or feet
14. Headaches or migraines (increase in frequency or intensity)
15. Weight (difficulty losing weight despite diet/exercise)
16. Bladder problems (difficulty in urinating, increased need to urinate)