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Mens ASM Questionnaire
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Full Name
*
Your answer
email
*
Your answer
Phone #
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Your answer
For the following Symptoms please rank each 0 - 5
Decline in your general feeling of well-being
None
1
2
3
4
5
extremely severe
Clear selection
Joint pain and muscular ache (lower back pain,joint pain, pain in a limb, general back ache)
1
2
3
4
5
Clear selection
Excessive sweating (unexpected/sudden episodesof sweating, hot flushes independent of strain)
1
2
3
4
5
Clear selection
Sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)
1
2
3
4
5
Clear selection
Increased need for sleep, often feeling tired.
1
2
3
4
5
Clear selection
Irritability (feeling aggressive, easily upset about little things, moody)
1
2
3
4
5
Clear selection
Nervousness (inner tension, restlessness, feeling fidgety)
1
2
3
4
5
Clear selection
Anxiety (feeling panicky)
1
2
3
4
5
Clear selection
Physical exhaustion / lacking vitality (general decrease in performance, reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, ofhaving to force oneself to undertake activities)
1
2
3
4
5
Clear selection
Decrease in muscular strength (feeling of weakness)
1
2
3
4
5
Clear selection
Depressive mood (feeling down, sad, on the verge of tears,lackofdrive,moodswings,feelingnothingisofanyuse)
1
2
3
4
5
Clear selection
Feeling that you have passed your peak
1
2
3
4
5
Clear selection
Feeling burnt out, having hit rock-bottom
1
2
3
4
5
Clear selection
Decrease in beard growth
1
2
3
4
5
Clear selection
Decrease in ability/frequency to perform sexually
1
2
3
4
5
Clear selection
Decrease in the number of morning erections
1
2
3
4
5
Clear selection
Decrease in sexual desire/libido (lacking pleasure in sex,lackingdesireforsexualintercourse)
1
2
3
4
5
Clear selection
Have you got any other major symptoms? If Yes, please describe or type "No".
Your answer
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