Wellness Form Questionnaire (Male)

Place an “X” for EACH symptom you are currently experiencing. Please mark only ONE box.
For symptoms that do not apply, please mark NONE.

    1. Decline in your feeling of general well-being (general state of health)

    2. Joint pain and muscular ache (back pain, joint pain, limb pain)

    3. Excessive sweating (unexpected/sudden sweating, hot flushes)

    4. Sleep problems (difficulty sleeping, poor sleep, early waking)

    5. Increased need for sleep, often feeling tired

    6. Irritability (easily upset, moody)

    7. Nervousness (fidgety, restlessness)

    8. Anxiety (feeling panicky)

    9. Physical exhaustion / lacking vitality (low performance, effort to engage)

    10. Decrease in muscular strength (feeling weak)

    11. Depressed mood (feeling down, sad, lack of drive)

    12. Feeling that you have passed your peak

    13. Feeling burnt out, having hit rock-bottom

    14. Decrease in beard growth

    15. Decrease in ability/frequency to perform sexually

    16. Decrease in number of morning erections

    17. Decrease in sexual desire/libido (less interest/pleasure)

    Additional comments:


    Other Health Questions:

    Do you have cold hands and feet?

    Do you have daily bowel movements?

    Do you have gas, bloating or abdominal pain after eating?

    Weekly Activity Level:

    Prior hormone therapy:

    Recent PSA:

    Recent Digital Rectal Exam (Date):
    Result:

    History of Prostate problems or Biopsy:


    Your Name:

    Your Email:

    Phone:

    4 × four =