Health Assessment for Men

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
Family History of Diabetes
Family History of Osteoporosis
Family History of Alzheimer’s Disease
Family History of Prostate Cancer
Do any of these apply to you?
Currently on testosterone therapy?
Currently on a 5a reductase inhibitor medication (see list below)?
Proscar (Finasteride), Avodart (Dutasteride), Jalyn (Dutasteride/Tamsulosin), Propecia (Finasteride)
Have prostate cancer?
Have Hashimoto's thyroiditis?
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?
When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
When you attempted sexual intercourse, how often was it satisfactory for you?
Calculation
Should be Empty:

Men's Health Assessment

Symptoms

Family History

Do any of these apply to you?

The Sexual Health Inventory for Men (SHIM) Questionnaire