First Name
Last Name
Phone
*
Email
*
Date of birth
Decline in your feeling of general well-being (general state of health, subjective feeling)
None
Mild
Moderate
Severe
Extremely Severe
Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache)
None
Mild
Moderate
Severe
Extremely Severe
Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain)
None
Mild
Moderate
Severe
Extremely Severe
Sleep problems (difficulty in falling asleep difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)
None
Mild
Moderate
Severe
Extremely Severe
Increased need for sleep, often feeling tired
None
Mild
Moderate
Severe
Extremely Severe
Irritability (feeling aggressive, easily upset about little things, moody)
None
Mild
Moderate
Severe
Extremely Severe
Nervousness (inner tension, restlessness, feeling fidgety)
None
Mild
Moderate
Severe
Extremely Severe
Anxiety (feeling panicky)
None
Mild
Moderate
Severe
Extremely Severe
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
Decrease in muscular strength (feeling of weakness)
None
Mild
Moderate
Severe
Extremely Severe
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
Feeling that you have passed your peak
None
Mild
Moderate
Severe
Extremely Severe
Feeling burnt out, having hit rock-bottom
None
Mild
Moderate
Severe
Extremely Severe
Decrease in beard growth
None
Mild
Moderate
Severe
Extremely Severe
Decrease in ability/frequency to perform sexually
None
Mild
Moderate
Severe
Extremely Severe
Decrease in the number of morning erections
None
Mild
Moderate
Severe
Extremely Severe
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.
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?