Hormone Replacement Therapy Symptom Checklist for MenPlease complete the form below, and we’ll be in touch shortly! We can't wait to hear from you! Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone (###) ### #### 1. Decline in your feeling of general well-being * General state of health, subjective feeling None Mild Moderate Severe Extremely Severe 2. Joint pain and muscle aches * Lower back pain, joint pain, pain in a limb, general back ache None Mild Moderate Severe Extremely Severe 3. Excessive sweating * Unexpected/sudden episodes of sweating, hot flashes independent of strain None Mild Moderate Severe Extremely Severe 4. Sleep problems * Difficulty in falling asleep, difficulty in sleeping through the night, waking up early and feeling tired, poor sleep, sleeplessness None Mild Moderate Severe Extremely Severe 5. Increased need for sleep, often feeling tired * None Mild Moderate Severe Extremely Severe 6. Irritability * Feeling aggressive, easily upset about little things, moody None Mild Moderate Severe Extremely Severe 7. Nervousness * Inner tension, restlessness, feeling fidgety None Mild Moderate Severe Extremely Severe 8. Anxiety * Feeling panicky None Mild Moderate Severe Extremely Severe 9. Physical exhaustion / lacking vitality * General decrease in performance, reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, of having to force oneself to undertake activities None Mild Moderate Severe Extremely Severe 10. Decrease in muscular strength * Feeling of weakness None Mild Moderate Severe Extremely Severe 11. Depressive mood * Feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use None Mild Moderate Severe Extremely Severe 12. Feeling that you have passed your peak * None Mild Moderate Severe Extremely Severe 13. Feeling burnt out, having hit rock-bottom * None Mild Moderate Severe Extremely Severe 14. Decrease in beard growth * None Mild Moderate Severe Extremely Severe 15. Decrease in ability/frequency to perform sexually * None Mild Moderate Severe Extremely Severe 16. Decrease in the number of morning erections * None Mild Moderate Severe Extremely Severe 17. Decrease in sexual desire/libido * Lacking pleasure in sex, lacking desire for sexual intercourse None Mild Moderate Severe Extremely Severe Please share any additional comments about your symptoms you would like to address. * If you don't have any comments, please write "None." Do you have cold hands and feet? * Yes No Do you have daily bowel movements? * Yes No Do you have gas, bloating, or abdominal pain after eating? * Yes No Please select your WEEKLY activity level based on this criteria: * Physical activity that accelerates heart rate / breathlessness 0-1 day per week (low) 2-3 days per week (average) More than 3 days per week (high) Please list any prior hormone therapy * If you've never had hormone therapy, please write "None." Please provide your most recent prostate-specific antigen (PSA) level * If you've never had a PSA level, please write "None" Date of most recent digital rectal exam (DRE) If you've never had a DRE, please leave blank. MM DD YYYY If you've had a digital rectal exam (DRE), please select if it was normal or abnormal * Normal Abnormal I haven't had a DRE before Do you have a history of prostate problems or biopsy? * If yes, please provide details, If no, please write "None." Thank you! I’ll be in touch with you shortly.