Mens Hormone Replacement Assessment

Name

Phone

Decline in your feeling of general well-being

Joint pain and muscular ache

Excessive sweating

Sleep problems

Increased need for sleep, often feeling tired

Irritability

Nervousness

Anxiety

Physical exhaustion / lacking vitality

Decrease in muscular strength

Depressive mood

Feeling that you have passed your peak

Feeling burnt out, having hit rock-bottom

Decrease in beard growth

Decrease in ability/frequency to perform sexually

Decrease in the number of morning erections

Decrease in sexual desire/libido

Please share any additional comments about your symptoms you would like to address.

Do you have cold hands and feet?

Do you have daily bowel movements?

Please select your WEEKLY Activity Level based on this criteria ➔ Physical activity that accelerates heart rate / Breathlessness

Please list any prior hormone therapy?

Have you had a recent PSA? If so, when?

Have you had a recent Rectal Exam? If so, when?

Do you have a history of Prostate problems or Biopsy. If so, please provide details.

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