BHRT CHECKLIST FOR MEN
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name:
*
Birthdate:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Symptom (please check mark)
*
Rows
Never
Mild
Moderate
Severe
Decline in general well being (General state of health)
Joint pain/muscle ache (Lower back/joint/limb pain)
Excessive sweating (Sudden episodes/hot flash)
Sleep problems (Difficulty falling/staying asleep/wake up tired)
Increased need for sleep (Feel tired often)
Irritability (Aggressive/easily upset/moody)
Nervousness (Inner tension/restlessness)
Anxiety (Feeling panicky)
Depressed mood (Feeling down/sad/lack of drive/nothing of any use)
Exhaustion/lacking vitality (Decreased performance & activity/lack of interest/motivation)
Declining Mental Ability/Focus/Concentration
Feeling you have passed your peak
Feeling burned out/hit rock bottom
Decreased muscle strength
Weight Gain/Belly Fat/Inability to Lose Weight
Breast Development
Shrinking Testicles
Rapid Hair Loss
Decrease in beard growth
New Migraine Headaches
Decreased desire/libido
Decreased morning erections
Decreased ability to perform sexually
Infrequent or Absent Ejaculations
No Results from E.D. Medications
Other symptoms that concern you:
*
Submit
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