Aging Males' Symptom (AMS)
Before HRT
Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Rate each symptom you are Experiencing. For symptoms that do not apply mark none
*
Rows
None
Mild
Moderate
Severe
Extremely Severe
1. Decline in your feeling of general well-being (general state of health, subjective feeling)
2. Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache)
3. Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain)
4. Sleep problems (difficulty in falling asleep difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)
5. Increased need for sleep, often feeling tired
6. Irritability (feeling aggressive, easily upset about little things, moody)
7. Nervousness (inner tension, restlessness, feeling fidgety)
8. Anxiety (feeling panicky)
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)
10. Decrease in muscular strength (feeling of weakness)
11. Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use)
12. Feeling that you have passed your peak
13. Feeling burnt out, having hit rock-bottom
14. Decrease in beard growth
15. Decrease in ability/frequency to perform sexually
16. Decrease in the number of morning erections
17. Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)
MRS Score
Severity
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 the criteria. This is physical activity that accelerates your heartrate/breathlessness
*
0-1 day per week (Low)
2-3 days per week (Average)
More than 3 days a week (High)
Please list any prior hormone therapy
Have you had a PSA in the past 2 years
*
Yes
No
History of prostate problems or biopsy? If yes Provide
*
Yes
No
Please explain your prostate history / biopsy details
Submit
Should be Empty: