Hormone Imbalance Symptom Screen For Men Hormone Imbalance Symptom Screen For Men Name * Name First First Last Last Date of Birth * Phone * Email * Address (number and street) City State Zip Code * Decline in your feeling of general well being (General state of health, subjective feeling) * None Mild Moderate Severe Extremely Severe Joint Pain & Muscular Ache (lower back pain, joint pain, pain in a limb, general back pain) * None Mild Moderate Severe Extremely Severe Excessive Sweating (unexpected sudden episodes of sweating) * None Mild Moderate Severe Extremely Severe Sleep Problems (difficulty falling or staying asleep, waking early & 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 Extremely Severe Physical Exhaustion/Lacking Vitality (general decrease in performance, reduced activity, lacking interest, getting less done) * 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) * None Mild Moderate Severe Extremely Severe Feeling 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 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 raises 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/current hormone therapy? * Have you had a recent PSA? * Yes No Recent Digital Rectal Exam (DRE) * Yes No If you answered yes to the last question was it normal or abnormal? Normal Abnormal History of Prostate problems or Biopsy. If so, please provide details. * If you are human, leave this field blank. Submit Δ