Male Health Assessment

First Name

Last Name

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Symptoms

Please mark the appropriate box for each symptom you may be experiencing.

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

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

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Irritability (mood swings, feeling aggressive, angers easily)

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

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

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

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

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Sexual Desire or Performance (reduced or diminished)

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Erectile changes (weaker erections, loss of morning erections)

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Ejaculations (infrequent or absent)

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Sweating (night sweats or increased episodes of sweating)

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Hair loss, thinning or change in texture of hair

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Feeling cold all the time, having cold hands or feet

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Headaches or migraines (increase in frequency or intensity)

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Weight (difficulty losing weight despite diet/exercise)

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

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Other symptoms or unique health circumstances to take into consideration:

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