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) Sweating (night sweats or excessive sweating)
Never
Mild
Moderate
Severe
Very Severe
2) Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)
Never
Mild
Moderate
Severe
Very Severe
3) Increased need for sleep or falls asleep easily after a meal
Never
Mild
Moderate
Severe
Very Severe
4) Depressive mood (feeling down, sad, lack of drive)
Never
Mild
Moderate
Severe
Very Severe
5) Irritability (mood swings, feeling aggressive, angers easily)
Never
Mild
Moderate
Severe
Very Severe
6) Anxiety (inner restlessness, feeling panicked, feeling nervous, inner tension)
Never
Mild
Moderate
Severe
Very Severe
7) 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
8) Sexual problems (change in sexual desire or in sexual performance)
Never
Mild
Moderate
Severe
Very Severe
9) Bladder problems (difficulty in urinating, increased need to urinate)
Never
Mild
Moderate
Severe
Very Severe
10) Erectile changes (weaker erections, loss of morning erections)
Never
Mild
Moderate
Severe
Very Severe
11) Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)
Never
Mild
Moderate
Severe
Very Severe
12) Difficulties with memory
Never
Mild
Moderate
Severe
Very Severe
13) Problems with thinking, concentrating, or reasoning
Never
Mild
Moderate
Severe
Very Severe
14) Difficulty learning new things
Never
Mild
Moderate
Severe
Very Severe
15) Trouble thinking of the right word to describe persons, places, or things when speaking
Never
Mild
Moderate
Severe
Very Severe
16) Increase in frequency or intensity of headaches/migraines
Never
Mild
Moderate
Severe
Very Severe
17) Rapid hair loss or thinning
Never
Mild
Moderate
Severe
Very Severe
18) Feel cold all the time or have cold hands or feet
Never
Mild
Moderate
Severe
Very Severe
19) Weight gain, increased belly fat, or difficulty losing weight despite diet and exercising
Never
Mild
Moderate
Severe
Very Severe
20) Infrequent or absent ejaculations
Never
Mild
Moderate
Severe
Very Severe
Severity Score
Severity score: Mild:1-20 / Moderate 21-40 / Severe 41-60 / Very Severe 61-80
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: