MALE HEALTH ASSESSMENT QUESTIONNAIRE Name * First Name Last Name Email * Cell Phone: (###) ### #### Today's Date: MM DD YYYY Please mark the appropriate box for each symptom you may be experiencing... Physical Exhaustion (fatigue, lack of energy, stamina or motivation): None Mild Moderate Severe Very Severe Sleep Problems (difficulty falling asleep or sleeping through the night): None Mild Moderate Severe Very Severe Irritability (mood swings, feeling aggressive, angers easily): None Mild Moderate Severe Very Severe Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous): None Mild Moderate Severe Very Severe Decline in drive or interest (loss of “zest for life,” feeling down or sad): None Mild Moderate Severe Very Severe Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise): None Mild Moderate Severe Very Severe Difficulties with memory (concentration, finding the right word, or retaining information): None Mild Moderate Severe Very Severe Sexual Desire or Performance (reduced or diminished): None Mild Moderate Severe Very Severe Erectile changes (weaker erections, loss of morning erections): None Mild Moderate Severe Very Severe Ejaculations (infrequent or absent): None Mild Moderate Severe Very Severe Sweating (night sweats or increased episodes of sweating): None Mild Moderate Severe Very Severe Hair loss, thinning or change in texture of hair: None Mild Moderate Severe Very Severe Feeling cold all the time, having cold hands or feet: None Mild Moderate Severe Very Severe Headaches or migraines (increase in frequency or intensity): None Mild Moderate Severe Very Severe Weight (difficulty losing weight despite diet/exercise): None Mild Moderate Severe Very Severe Bladder problems (difficulty in urinating, increased need to urinate, incontinence): None Mild Moderate Severe Very Severe Other symptoms or unique health circumstances to take into consideration: Thank you! A member of our medical team will be in touch within 24 business hours to discuss your survey and next steps!
