Name *

First Name

Last Name

Cell Phone:

(###)

###

####

Today's Date:

MM

DD

YYYY

Physical Exhaustion (fatigue, lack of energy, stamina or motivation):

None

Mild

Moderate

Severe

Very Severe

Sleep Problems (difficulty falling asleep or sleeping through the night):

None

Mild

Moderate

Severe

Very Severe

Irritability (mood swings, feeling aggressive, angers easily):

None

Mild

Moderate

Severe

Very Severe

Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous):

None

Mild

Moderate

Severe

Very Severe

Decline in drive or interest (loss of “zest for life,” feeling down or sad):

None

Mild

Moderate

Severe

Very Severe

Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise):

None

Mild

Moderate

Severe

Very Severe

Difficulties with memory (concentration, finding the right word, or retaining information):

None

Mild

Moderate

Severe

Very Severe

Female - Vaginal dryness or difficulty with sexual intercourse:

None

Mild

Moderate

Severe

Very Severe

Female - Sexual Problems (change in desire, activity, orgasm and/or satisfaction):

None

Mild

Moderate

Severe

Very Severe

Female - Hot Flashes (burst that starts in chest and lasts for short duration):

None

Mild

Moderate

Severe

Very Severe

Male - Sexual Desire or Performance (reduced or diminished):

None

Mild

Moderate

Severe

Very Severe

Male - Erectile changes (weaker erections, loss of morning erections):

None

Mild

Moderate

Severe

Very Severe

Male - Ejaculations (infrequent or absent):

None

Mild

Moderate

Severe

Very Severe

Sweating (night sweats or increased episodes of sweating):

None

Mild

Moderate

Severe

Very Severe

Hair loss, thinning or change in texture of hair:

None

Mild

Moderate

Severe

Very Severe

Feeling cold all the time, having cold hands or feet:

None

Mild

Moderate

Severe

Very Severe

Headaches or migraines (increase in frequency or intensity):

None

Mild

Moderate

Severe

Very Severe

Weight (difficulty losing weight despite diet/exercise):

None

Mild

Moderate

Severe

Very Severe

Bladder problems (difficulty in urinating, increased need to urinate, incontinence):

None

Mild

Moderate

Severe

Very Severe