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HORMONE TREATMENT MALE
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Name
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Date of Birth
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Height (inches)
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Weight (lbs)
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Decline in your feeling of general well-being (general state of health, subjective feeling)
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Joint pain and muscular ache (lower back pain, joint pain, pain in limb, general back ache)
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Excessive Sweating ( unexpected/sudden episodes of sweating, hot flashes independent of strain)
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Sleep Problems (difficulty falling asleep, sleeping through the night, waking up too early and feeling tired, poor sleep)
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Increased need for sleep, often feeling tired)
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Irritability (feeling aggressive, easily upset about little things, moody)
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Nervousness (inner tension, restlessness, feeling fidgety)
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Anxiety (feeling panicky)
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Physical Exhaustion / Lacking Vitality (General decrease in performance, activity, interest in leisure, lack of motivation)
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Decrease in muscular strength (feeling of weakness)
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Depressive Mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)
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Feeling you have passed your peak
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Feeling burnt out, having hit rock bottom
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Decrease in Beard Growth
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Decrease in ability/ frequency to perform sexually
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Decrease in the number of morning erections
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Decreased libido / Sexual Desire (lacking pleasure in sex, lacking desire for intercourse)
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Do you have cold hands and feet?
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Do you have daily bowel movements?
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Do you have gas, bloating, or abdominal pain after eating?
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Please select your weekly activity level
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Please share any additional comments about your symptoms you would like to address.
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