MEN’S HORMONE DEFICIENCY SCREENING - BEFORE HRT
5301 Alpha Road Suite 34, Room 21 - Dallas, TX 75240 Phone: 214-890-6180 | Fax: 1-214-241-4792 Email: contact@jaenixmedspa.com
Section 1 — Your Information
Please provide your contact and demographic details.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age Range
*
Please Select
18–29
30–39
40–49
50–59
60+
Date of Birth (DOB)
*
-
Month
-
Day
Year
Date
AMS Symptom Checklist
*
Rows
None
Mild
Moderate
Severe
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)
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
Please select your WEEKLY Activity Level (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)
Please list any prior hormone therapy:
Recent PSA:
Recent Digital Rectal Exam (Date):
Digital Rectal Exam Result
Normal
Abnormal
History of prostate problems or biopsy. If so, please provide details:
Submit
Should be Empty: