Health Assessment for Men

Men's Health Assessment
Daniel *

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
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