Hormone Checklist - Male

You can always press Enter⏎ to continue

Hormone Checklist - Male

Please do your best to fill out the form below. Once you complete our "Hormone Checklist", you will be able to schedule a call with one of our highly-trained pharmacists to discuss your answers. Hit the "START" button below to get started.

1
What Is Your Name?* This field is required.
First Name
Last Name
2
Estrogen Dominance* This field is required.Please select the answer which best describes the severity of your symptoms.
None
Mild
Moderate
Severe
Decreased Urine Flow
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Increased Urinary Urge
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Known Prostate Problems
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Decreased Urine Flow
Increased Urinary Urge
Known Prostate Problems
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
1 of 3
3
Metabolic Syndrome / Low Androgens* This field is required.Please select the answer which best describes the severity of your symptoms.
None
Mild
Moderate
Severe
Weight Gain – Chest / Hips
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Weight Gain – Waist
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Decreased Libido
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Decreased Erections
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Ringing in Ears
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
High Cholesterol
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Elevated Triglycerides
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Hot Flashes
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Night Sweats
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Decreased Mental Sharpness
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Increased Forgetfulness
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Weight Gain – Chest / Hips
Weight Gain – Waist
Decreased Libido
Decreased Erections
Ringing in Ears
High Cholesterol
Elevated Triglycerides
Hot Flashes
Night Sweats
Decreased Mental Sharpness
Increased Forgetfulness
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
1 of 11
4
Metabolic Syndrome / Low Androgens (continued)* This field is required.Please select the answer which best describes the severity of your symptoms.
None
Mild
Moderate
Severe
Decreased Muscle Size
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Decreased Flexibility
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Sore Muscles
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Increased Joint Pain
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Neck or Back Pain
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Bone Loss
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Rapid Aging
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Thinning Skin
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Decreased Stamina
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Burned Out Feeling
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Infertility Problems
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Decreased Muscle Size
Decreased Flexibility
Sore Muscles
Increased Joint Pain
Neck or Back Pain
Bone Loss
Rapid Aging
Thinning Skin
Decreased Stamina
Burned Out Feeling
Infertility Problems
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
1 of 11
5
Thyroid/ Other* This field is required.Please select the answer which best describes the severity of your symptoms.
None
Mild
Moderate
Severe
Cold Body Temperature
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Goiter
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Hoarseness
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Hair Dry or Brittle
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Nails Breaking or Brittle
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Constipation
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Slow Pulse Rate
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Rapid Heartbeat
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Heart Palpitations
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Cold Body Temperature
Goiter
Hoarseness
Hair Dry or Brittle
Nails Breaking or Brittle
Constipation
Slow Pulse Rate
Rapid Heartbeat
Heart Palpitations
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
1 of 9
6
* This field is required.
Should be Empty:

Question Label

1 of 6See AllGo Back