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MALE HEALTH ASSESSMENT
PLEASE RATE THE SEVERITY OF YOUR SYMPTOMS BELOW:
NONE
MILD
MODERATE
SEVERE
Physical Exhaustion (fatigue, lack of energy, stamina or motivation)
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Sleep Problems (difficulty falling asleep or sleeping through the night)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Irritability (mood swings, feeling aggressive, angers easily)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous)
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Decline in drive or interest (loss of “zest for life,” feeling down or sad)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Difficulties with memory (concentration, finding the right word, or retaining information)
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Sexual Desire or Performance (reduced or diminished)
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Erectile changes (weaker erections, loss of morning erections)
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Ejaculations (infrequent or absent)
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Sweating (night sweats or increased episodes of sweating)
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Weight (difficulty losing weight despite diet/exercise)
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Hair loss, rapid or thinning
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Feeling cold all the time, having cold hands or feet
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Headaches or migraines (increase in frequency or intensity)
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Bladder problems (difficulty in urinating, increased need to urinate
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Physical Exhaustion (fatigue, lack of energy, stamina or motivation)
Sleep Problems (difficulty falling asleep or sleeping through the night)
Irritability (mood swings, feeling aggressive, angers easily)
Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous)
Decline in drive or interest (loss of “zest for life,” feeling down or sad)
Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise)
Difficulties with memory (concentration, finding the right word, or retaining information)
Sexual Desire or Performance (reduced or diminished)
Erectile changes (weaker erections, loss of morning erections)
Ejaculations (infrequent or absent)
Sweating (night sweats or increased episodes of sweating)
Weight (difficulty losing weight despite diet/exercise)
Hair loss, rapid or thinning
Feeling cold all the time, having cold hands or feet
Headaches or migraines (increase in frequency or intensity)
Bladder problems (difficulty in urinating, increased need to urinate
NONE
Row 0, Column 0
MILD
Row 0, Column 1
MODERATE
Row 0, Column 2
SEVERE
Row 0, Column 3
NONE
Row 1, Column 0
MILD
Row 1, Column 1
MODERATE
Row 1, Column 2
SEVERE
Row 1, Column 3
NONE
Row 2, Column 0
MILD
Row 2, Column 1
MODERATE
Row 2, Column 2
SEVERE
Row 2, Column 3
NONE
Row 3, Column 0
MILD
Row 3, Column 1
MODERATE
Row 3, Column 2
SEVERE
Row 3, Column 3
NONE
Row 4, Column 0
MILD
Row 4, Column 1
MODERATE
Row 4, Column 2
SEVERE
Row 4, Column 3
NONE
Row 5, Column 0
MILD
Row 5, Column 1
MODERATE
Row 5, Column 2
SEVERE
Row 5, Column 3
NONE
Row 6, Column 0
MILD
Row 6, Column 1
MODERATE
Row 6, Column 2
SEVERE
Row 6, Column 3
NONE
Row 7, Column 0
MILD
Row 7, Column 1
MODERATE
Row 7, Column 2
SEVERE
Row 7, Column 3
NONE
Row 8, Column 0
MILD
Row 8, Column 1
MODERATE
Row 8, Column 2
SEVERE
Row 8, Column 3
NONE
Row 9, Column 0
MILD
Row 9, Column 1
MODERATE
Row 9, Column 2
SEVERE
Row 9, Column 3
NONE
Row 10, Column 0
MILD
Row 10, Column 1
MODERATE
Row 10, Column 2
SEVERE
Row 10, Column 3
NONE
Row 11, Column 0
MILD
Row 11, Column 1
MODERATE
Row 11, Column 2
SEVERE
Row 11, Column 3
NONE
Row 12, Column 0
MILD
Row 12, Column 1
MODERATE
Row 12, Column 2
SEVERE
Row 12, Column 3
NONE
Row 13, Column 0
MILD
Row 13, Column 1
MODERATE
Row 13, Column 2
SEVERE
Row 13, Column 3
NONE
Row 14, Column 0
MILD
Row 14, Column 1
MODERATE
Row 14, Column 2
SEVERE
Row 14, Column 3
NONE
Row 15, Column 0
MILD
Row 15, Column 1
MODERATE
Row 15, Column 2
SEVERE
Row 15, Column 3
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