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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)
Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)
Increased need for sleep or falls asleep easily after a meal
Depressive mood (feeling down, sad, lack of drive)
Irritability (mood swings, feeling aggressive, angers easily)
Anxiety (inner restlessness, feeling panicked, feeling nervous, inner tension)
Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)
Sexual problems (change in sexual desire or in sexual performance)
Bladder problems (difficulty in urinating, increased need to urinate)
Erectile changes (weaker erections, loss of morning erections)
Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)
Difficulties with memory
Problems with thinking, concentrating or reasoning
Difficulty learning new things
Trouble thinking of the right word to describe persons, places or things when speaking
Increase in frequency or intensity of headaches/migraines
Rapid hair loss or thinning
Feel cold all the time or have cold hands or feet
Weight gain, increased belly fat, or difficulty losing weight despite diet and exercise
Infrequent or absent ejaculations
No Result from E.D. medications E29.1
Family History
No
Yes
Heart Disease
Diabetes
Osteoporosis
Alzheimer's Disease
Stroke
Age
Weight
Smoker YesNo
History of Prostrate Cancer YesNo
Currently on Dialysis YesNo
Thyroid Medication/dose
Current Hormone Replacement Therapy
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