Full Name *

Email *

Phone *

Insurance

Please type your health insurance company

Member ID

Please type your health insurance member ID

Group ID

Please type your health insurance group ID

Please describe any decline in your feeling of general well-being (general state of health, subjective feeling). *

Please describe any joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache). *

Please describe any excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain). *

Please describe any sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness). *

Please describe any physical exhaustion / lacking vitality (general decrease in performance, reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, of having to force oneself to undertake activities). *

Please describe any depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use). *

Please describe any decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse). *

Please share any additional comments about your symptoms you would like to address:

Do you have cold hands and feet? *

Yes

Do you have daily bowel movements? *

Yes

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

Yes

Please select your WEEKLY Activity Level based on this criteria: *

Physical activity that accelerates heart rate / breathlessness

0-1 day per week (Low)

2-3 days per week (Average)

More than 3 days per week (High)

Please list any prior hormone therapy treatments:

What was your recent prostate-specific antigen (PSA) blood test value?

When was the last time (date) you had a digital rectal exam and where the findings normal or abormal?

Do you have history of prostate problems or had a biopsy? If so, please also provide details: