MEN- bioTE BHRT Checklist

Health Assesment

For Men
Date

Month Day Year
Date
Name

First Name Last Name
DOB

Month Day Year
Date
Email
example@example.com
Phone Number

Area Code Phone Number
Symptom (select one option for each symptom)
Decline in general well being

Never Mild Moderate Severe
Fatigue

Never Mild Moderate Severe
Joint pain/ muscle ache

Never Mild Moder Severe
Excessive Sweating

Never Mild Moderate Severe
Sleep Problems

Never Mild Moderate Severe
Increased need for sleep

Never Mild Moderate Severe
Irritability

Never Mild Moderate Severe
Nervousness

Never Mild Moderate Severe
Depressed Mood

Never Mild Moderate Severe
Exhaustion/ lacking vitality

Never Mild Moderate Severe
Declining Mental Ability/ Focus/ Concentration

Never Mild Moderate Severe
Feeling you have passed your peak

Never Mild Moderate Severe

Feeling burned out/ hit rock bottom

Never Mild Moderate Severe
Decreased muscle strength

Never Mild Moderate Severe
Weight Gain/ Belly Fat/ Inability to lose weight

Never Mild Moderate Severe
Breast Development?

Never Mild Moderate Severe
Shrinking Testicles

Never Mild Moderate Severe
Rapid Hair Loss

Never Mild Moderate Severe
Decrease in beard growth

Never Mild Moderate Severe
New migraine headaches

Never Mild Moderate Severe
Decreased desire/ libido

Never Mild Moderate Severe
Decreased morning erections

Never Mild Moderate Severe
Decreased ability to perform sexually

Never Mild Moderate Severe
Infrequent or absent ejaculations

Never Mild Moderate Severe
No results from E.D. Medications

Never Mild Moderate Severe
Family History/ Activity Level
Heart Disease?
Diabetes
Osteoporosis
Alzheimer's Disease
Activity Level
Should be Empty:

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