Please select for EACH symptom you are currently experiencing

For symptoms that do not apply, please mark NONE.

Decline in your feeling of general well-being *
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Joint and muscular discomfort (Lower back pain, joint pain)*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Excessive sweating (unexpected/sudden episodes of sweating)*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Sleep problems (Difficulty in falling asleep)*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Increased need for sleep, often feeling tired*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Irritability (Feeling aggressive, easily upset about little things)*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Nervousness (inner tension, restlessness, feeling fidgety)*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Anxiety (Inner restlessness, feeling panicky)*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Physical exhaustion (General decrease in performance)*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Decrease in muscular strength (feeling of weakness)*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Depressive mood (Feeling down, sad, on the verge of tears)*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Feeling that you have passed your peak *
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Feeling burnt out, having hit rock-bottom*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Decrease in beard growth*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Decrease in ability/frequency to perform sexually*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Decrease in the number of morning erections*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Decrease in sexual desire/libido*
  • None
  • Mild
  • Moderate
  • Severe
  • Extremely Severe
  • No elements found. Consider changing the search query.
  • List is empty.
Do you have cold hands and feet?*
  • Yes
  • No
  • No elements found. Consider changing the search query.
  • List is empty.
Do you have daily bowel movements?*
  • Yes
  • No
  • No elements found. Consider changing the search query.
  • List is empty.
Do you have gas, bloating or abdominal pain after eating?*
  • Yes
  • No
  • No elements found. Consider changing the search query.
  • List is empty.

Please select your WEEKLY Activity Level based on this criteria  Physical activity that accelerates heart rate / Breathlessness

By completing this form, you are giving us permission to follow-up by phone, email or text.