Biote-Men-Quiz | Svelte Medical Weight Loss

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MALE HEALTH ASSESSMENT

Which of the following symptoms apply to you currently (in the last 2 weeks)? Please mark the appropriate box
for each symptom. For symptoms that do not currently apply or no longer apply, mark “none”.

Symptom	Never	Mild	Moderate	Severe	Very Severe
Sweating (night sweats or excessive sweating)	Never	Mild	Moderate	Severe	Very Severe
Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)	Never	Mild	Moderate	Severe	Very Severe
Increased need for sleep or falls asleep easily after a meal	Never	Mild	Moderate	Severe	Very Severe
Depressive mood (feeling down, sad, lack of drive)	Never	Mild	Moderate	Severe	Very Severe
Irritability (mood swings, feeling aggressive, angers easily)	Never	Mild	Moderate	Severe	Very Severe
Anxiety (inner restlessness, feeling panicked, feeling nervous, inner tension)	Never	Mild	Moderate	Severe	Very Severe
Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)	Never	Mild	Moderate	Severe	Very Severe
Sexual problems (change in sexual desire or in sexual performance)	Never	Mild	Moderate	Severe	Very Severe
Bladder problems (difficulty in urinating, increased need to urinate)	Never	Mild	Moderate	Severe	Very Severe
Erectile changes (weaker erections, loss of morning erections)	Never	Mild	Moderate	Severe	Very Severe
Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)	Never	Mild	Moderate	Severe	Very Severe
Difficulties with memory	Never	Mild	Moderate	Severe	Very Severe
Problems with thinking, concentrating or reasoning	Never	Mild	Moderate	Severe	Very Severe
Difficulty learning new things	Never	Mild	Moderate	Severe	Very Severe
Trouble thinking of the right word to describe persons, places or things when speaking	Never	Mild	Moderate	Severe	Very Severe
Increase in frequency or intensity of headaches/migraines	Never	Mild	Moderate	Severe	Very Severe
Rapid hair loss or thinning	Never	Mild	Moderate	Severe	Very Severe
Feel cold all the time or have cold hands or feet	Never	Mild	Moderate	Severe	Very Severe
Weight gain, increased belly fat, or difficulty losing weight despite diet and exercise	Never	Mild	Moderate	Severe	Very Severe
Infrequent or absent ejaculations	Never	Mild	Moderate	Severe	Very Severe
No Result from E.D. medications E29.1	Never	Mild	Moderate	Severe	Very Severe

Family History	No	Yes
Heart Disease	No	Yes
Diabetes	No	Yes
Osteoporosis	No	Yes
Alzheimer's Disease	No	Yes
Stroke	No	Yes

Age

Weight

Smoker
YesNo

History of Prostrate Cancer
YesNo

Currently on Dialysis
YesNo

Thyroid Medication/dose

Current Hormone Replacement Therapy

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