MALE HEALTH ASSESSMENT QUESTIONNAIRE
Help us understand your current health status and identify specific areas of concern. By evaluating symptoms such as fatigue, sleep disturbances and decline in muscle mass, we can determine your candidacy for hormone imbalance and lab testing. Please answer the questions provided below about how you've felt over the last 30 days.
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First Name:  *
Email Address: *
Phone Number: *
SYMPTOMS
None
Mild
Moderate
Severe
Very Severe
Physical Exhaustion (fatigue, lack of energy, stamina or motivation)
Sleep Problems (difficulty falling asleep or sleeping through the night)
Irritability (mood swings, feeling aggressive, angers easily)
Anxiety (feeling overwhelmed, panicky or nervous)
Decline in drive or interest (loss of “zest for life, feeling down or sad)”
Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise)
Difficulties with memory (concentration, finding the right word, or retaining information)
Sexual Desire Or Performance (reduced or diminished)
Erectile changes (weaker erections, loss of morning erections)
Ejaculations (infrequent or absent)
Sweating (night sweats or increased episodes of sweating)
Hair loss, rapid or thinning
Feeling cold all the time, having cold hands or feet
Headaches or migraines (increase in frequency or intensity)
Weight (difficulty losing weight despite diet/exercise)
Bladder problems (difficulty in urinating, increased need to urinate)
Other symptoms or unique health circumstances to take into consideration(If no please answer N/A):
 *
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