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


    YesNo


    YesNo


    YesNo

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