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


    Yes No


    Yes No


    Yes No

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