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Stem Cell Therapy
Exosome Therapy
Female Hormone Replacement Therapy Scottsdale, AZ
About
Contact
Services
Stem Cell Therapy
Exosome Therapy
Female Hormone Replacement Therapy Scottsdale, AZ
(480) 270-8318
Mens Hormone Replacement Assessment
Name
Phone
Decline in your feeling of general well-being
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Joint pain and muscular ache
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Excessive sweating
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Sleep problems
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Increased need for sleep, often feeling tired
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Irritability
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Nervousness
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Anxiety
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Physical exhaustion / lacking vitality
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Decrease in muscular strength
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Depressive mood
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Feeling that you have passed your peak
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Feeling burnt out, having hit rock-bottom
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Decrease in beard growth
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Decrease in ability/frequency to perform sexually
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Decrease in the number of morning erections
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Decrease in sexual desire/libido
1- None
2- Mild
3- Moderate
4- Severe
5- Extremely Severe
Please share any additional comments about your symptoms you would like to address.
Do you have cold hands and feet?
Yes
No
Do you have daily bowel movements?
Yes
No
Please select your WEEKLY Activity Level based on this criteria ➔ Physical activity that accelerates heart rate / Breathlessness
0-1 Times per week (Low)
2-3 Times per week (Average)
More than 3 times per week (High)
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.
Send
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