Advanced HRT Symptom Survey
This survey screens for problems with DHEA and Pregnenolone
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Now
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age (calculated, office use)
Please indicated if you have any past history of the following:
*
Rows
Yes, currently
Yes, in the Past
No, never
Unsure
Chronic Pain
PTSD
Head Trauma (TBI)
Concussion
Anabolic Steroid Use
Stress (emotional, physical, or spiritual)
Cancer
Have you ever used anabolic steroids? If so, how old were you when you started?
1a. Do you have any symptoms of reduced penis sensitivity and inability to orgasm?
*
Almost never or never
A few times (much less than half of the time)
Sometimes (about half of the time)
Most times (much more than have of the time)
Almost always or always
2a. Erectile dysfunction
*
Almost never or never
A few times (much less than half of the time)
Sometimes (about half of the time)
Most times (much more than have of the time)
Almost always or always
3a. Do you have any symptoms of reduced sex drive (libido)?
*
Almost never or never
A few times (much less than half of the time)
Sometimes (about half of the time)
Most times (much more than have of the time)
Almost always or always
4a. Any symptoms of premature ejaculation or increased penile sensitivity?
*
Almost never or never
A few times (much less than half of the time)
Sometimes (about half of the time)
Most times (much more than have of the time)
Almost always or always
5a. Low mood or feeling depressed
*
Almost never or never
A few times (much less than half of the time)
Sometimes (about half of the time)
Most times (much more than have of the time)
Almost always or always
6a. Symptoms of fatigue and low energy
*
Almost never or never
A few times (much less than half of the time)
Sometimes (about half of the time)
Most times (much more than have of the time)
Almost always or always
Total for DHEA deficiency symptoms (-5 to 26)
1b. Constant feeling of internal tension "Fight or flight", restlessness
*
Almost never or never
A few times (much less than half of the time)
Sometimes (about half of the time)
Most times (much more than have of the time)
Almost always or always
2b. Inability to relax and "switch off"
*
Almost never or never
A few times (much less than half of the time)
Sometimes (about half of the time)
Most times (much more than have of the time)
Almost always or always
3b. Feeling overwhelmed by easy tasks
*
Almost never or never
A few times (much less than half of the time)
Sometimes (about half of the time)
Most times (much more than have of the time)
Almost always or always
4b. Low level of joy or satisfaction
*
Almost never or never
A few times (much less than half of the time)
Sometimes (about half of the time)
Most times (much more than have of the time)
Almost always or always
5b. Hypersensitivity to intoxicants (especially THC and caffeine)
*
Almost never or never
A few times (much less than half of the time)
Sometimes (about half of the time)
Most times (much more than have of the time)
Almost always or always
6b. Brain fog, poor memory, brain not working properly
*
Almost never or never
A few times (much less than half of the time)
Sometimes (about half of the time)
Most times (much more than have of the time)
Almost always or always
Total for Pregnenolone deficiency symptoms (0-30)
Submit
Should be Empty: