Men's Health Assessment
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Symptoms
Please rate each symptom below as: Never, Mild, Moderate, or Severe
1) Fatigue
Never
Mild
Moderate
Severe
2) Mood Changes: Irritability
Never
Mild
Moderate
Severe
2a) Mood Changes: Anxiety
Never
Mild
Moderate
Severe
2b) Mood Changes: Nervousness
Never
Mild
Moderate
Severe
2c) Mood Changes: Depression
Never
Mild
Moderate
Severe
3) Decreased Mental Ability: Memory Loss
Never
Mild
Moderate
Severe
3a) Decreased Mental Ability: Confusion
Never
Mild
Moderate
Severe
3b) Decreased Mental Ability: Loss of Focus
Never
Mild
Moderate
Severe
4) Excessive Sweating
Never
Mild
Moderate
Severe
5) Weight Gain: Bloating
Never
Mild
Moderate
Severe
5a) Weight Gain: Excessive Belly Fat
Never
Mild
Moderate
Severe
5b) Weight Gain: Inability to Lose Weight
Never
Mild
Moderate
Severe
6) Decreased Sex Drive
Never
Mild
Moderate
Severe
6a) No Morning Erections
Never
Mild
Moderate
Severe
7) Sleep Problems: Can’t Stay Asleep
Never
Mild
Moderate
Severe
7a) Sleep Problems: Can’t Fall Asleep
Never
Mild
Moderate
Severe
8) Decreased Muscle Strength
Never
Mild
Moderate
Severe
9) Hair loss/breakage
Never
Mild
Moderate
Severe
10) Joint Pain/Muscle Aches
Never
Mild
Moderate
Severe
11) Do you ever have difficulty achieving or maintaining an erection?
Never
Mild
Moderate
Severe
Family History
Family History of Heart Disease
Yes
No
Family History of Diabetes
Yes
No
Family History of Osteoporosis
Yes
No
Family History of Alzheimer’s Disease
Yes
No
Family History of Prostate Cancer
Yes
No
Do any of these apply to you?
Currently on testosterone therapy?
Yes
No
Currently on a 5a reductase inhibitor medication (see list below)?
Proscar (Finasteride), Avodart (Dutasteride), Jalyn (Dutasteride/Tamsulosin), Propecia (Finasteride)
Have prostate cancer?
Yes
No
Have Hashimoto's thyroiditis?
Yes
No
Are you currently on Thyroid medication?
Are you currently on Statins?
What is your activity level?
Low
Moderate
Average
High
What is your current weight?
The Sexual Health Inventory for Men (SHIM) Questionnaire
Over the past 6 months...
How would you rate your confidence that you could get and keep an erection?
Very low
Low
Moderate
High
Very high
When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
No sexual activity
Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always or always
During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
Did not attempt intercourse
Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always or always
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
Did not attempt intercourse
Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult
When you attempted sexual intercourse, how often was it satisfactory for you?
Did not attempt intercourse
Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always or always
Calculation
Submit
Should be Empty: