Health Assesment
For Men
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Symptom
(select one option for each symptom)
Decline in general well being
Never
Mild
Moderate
Severe
Fatigue
Never
Mild
Moderate
Severe
Joint pain/ muscle ache
Never
Mild
Moder
Severe
Excessive Sweating
Never
Mild
Moderate
Severe
Sleep Problems
Never
Mild
Moderate
Severe
Increased need for sleep
Never
Mild
Moderate
Severe
Irritability
Never
Mild
Moderate
Severe
Nervousness
Never
Mild
Moderate
Severe
Depressed Mood
Never
Mild
Moderate
Severe
Exhaustion/ lacking vitality
Never
Mild
Moderate
Severe
Declining Mental Ability/ Focus/ Concentration
Never
Mild
Moderate
Severe
Feeling you have passed your peak
Never
Mild
Moderate
Severe
Back
Next
Feeling burned out/ hit rock bottom
Never
Mild
Moderate
Severe
Decreased muscle strength
Never
Mild
Moderate
Severe
Weight Gain/ Belly Fat/ Inability to lose weight
Never
Mild
Moderate
Severe
Breast Development?
Never
Mild
Moderate
Severe
Shrinking Testicles
Never
Mild
Moderate
Severe
Rapid Hair Loss
Never
Mild
Moderate
Severe
Decrease in beard growth
Never
Mild
Moderate
Severe
New migraine headaches
Never
Mild
Moderate
Severe
Decreased desire/ libido
Never
Mild
Moderate
Severe
Decreased morning erections
Never
Mild
Moderate
Severe
Decreased ability to perform sexually
Never
Mild
Moderate
Severe
Infrequent or absent ejaculations
Never
Mild
Moderate
Severe
No results from E.D. Medications
Never
Mild
Moderate
Severe
Family History/ Activity Level
Heart Disease?
Yes
No
Diabetes
Yes
No
Osteoporosis
Yes
No
Alzheimer's Disease
Yes
No
Activity Level
Low
Moderate
Moderately High
High
Submit
Should be Empty: