Male Checklist - BEFORE HRT
Name
*
Cell
*
E-Mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
*
Weight
*
DOB
*
-
Month
-
Day
Year
Date
Select a number for the symptom you are currently experiencing.
1: None 2: Mild 3: Moderate 4: Severe 5: Extremely Severe
Decline in your feeling of general well-being (general state of health, subjective feeling)
*
Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache)
*
Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain)
*
Sleep problems (difficulty in falling asleep difficulty in sleeping through,waking up early and feeling tired, poor sleep, sleeplessness)
*
Increased need for sleep, often feeling tired
*
Irritability (feeling aggressive, easily upset about little things, moody)
*
Nervousness (inner tension, restlessness, feeling fidgety)
*
Anxiety (feeling panicky)
*
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)
*
Decrease in muscular strength (feeling of weakness)
*
Decline in your feeling of general well-being (general state of health, subjective feeling)
*
Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use)
*
Feeling that you have passed your peak
*
Feeling burnt out, having hit rock-bottom
*
Decrease in beard growth
*
Decrease in ability/frequency to perform sexually
*
Decrease in the number of morning erections
*
Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)
*
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
On 5a Reductase?
*
Yes
No
Had Urological Work-Up Performed & OK?
*
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)
Have you had a recent prostate exam?
*
History of Prostate problems or Biopsy. If so, please provide details.
Do you know your most recent PSA lab level? If so, what is it?
Please list any prior hormone therapy?
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