Name: E-Mail: ________________________________ Symptom (please check mark) Never Mild Decline in general well being Fatigue Joint pain/muscle ache Excessive sweating Sleep problems Increased need for sleep Irritability Nervousness Anxiety Depressed mood Exhaustion/lacking vitality Declining Mental Ability/Focus/Concentration Feeling you have passed your peak Feeling burned out/hit rock bottom Decreased muscle strength Weight Gain/Belly Fat/Inability to Lose Weight Breast Development Shrinking Testicles Rapid Hair Loss Decrease in beard growth New Migraine Headaches Decreased desire/libido Decreased morning erections Decreased ability to perform sexually Infrequent or Absent Ejaculations No Results from E.D. Medications Family History NO YES Heart Disease Diabetes Osteoporosis Alzheimer’s Disease
Name: E-Mail: ________________________________ Symptom (please check mark) Never Mild Decline in general well being Fatigue Joint pain/muscle ache Excessive sweating Sleep problems Increased need for sleep Irritability Nervousness Anxiety Depressed mood Exhaustion/lacking vitality Declining Mental Ability/Focus/Concentration Feeling you have passed your peak Feeling burned out/hit rock bottom Decreased muscle strength Weight Gain/Belly Fat/Inability to Lose Weight Breast Development Shrinking Testicles Rapid Hair Loss Decrease in beard growth New Migraine Headaches Decreased desire/libido Decreased morning erections Decreased ability to perform sexually Infrequent or Absent Ejaculations No Results from E.D. Medications Family History NO YES Heart Disease Diabetes Osteoporosis Alzheimer’s Disease