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/Anxiety/Nervousness/Depression

Never Mild Moderate Severe
3) Decreased Mental Ability: Memory Loss/Confusion/Loss of Focus

Never Mild Moderate Severe
4) Excessive Sweating

Never Mild Moderate Severe
5) Weight Gain: Bloating, Excessive Belly Fat, Inability to Lose Weight

Never Mild Moderate Severe
6) Decreased Sex Drive: No Morning Erections

Never Mild Moderate Severe
7) Sleep Problems: Can’t Stay Asleep/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
Family History
Heart Disease
Diabetes
Osteoporosis
Alzheimer’s Disease
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?
Should be Empty:

Men's Health Assessment