Hormone Imbalance Symptom Screen For Men
Name
Name
First
Last
Decline in your feeling of general well being (General state of health, subjective feeling)
Joint Pain & Muscular Ache (lower back pain, joint pain, pain in a limb, general back pain)
Excessive Sweating (unexpected sudden episodes of sweating)
Sleep Problems (difficulty falling or staying asleep, waking early & feeling tired, poor sleep, sleeplessness)
Increased need for sleep, often feeling tired
Irritability (feeling aggressive, easily upset about little things, moody)
Nervousness (inner tension, restlessness, feeling fidgety)
Anxiety (feeling panicky)
Physical Exhaustion/Lacking Vitality (general decrease in performance, reduced activity, lacking interest, getting less done)
Decrease in muscular strength (feeling of weakness)
Depressive Mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)
Feeling 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 number of morning erections
Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)
Do you have cold hands and feet?
Do you have daily bowel movements?
Do you have gas, bloating or abdominal pain after eating?
Please select your WEEKLY activity level based on this criteria (Physical activity that raises heart rate/breathlessness)
Have you had a recent PSA?
Recent Digital Rectal Exam (DRE)
If you answered yes to the last question was it normal or abnormal?