Past or Present Condition (0 = none, 10 = yes) Ovarian Cancer Infertility (never able to conceive) Uterine Cancer Loss of height/ bone loss Cervical Cancer Miscarriage Breast Cancer Premature menopause (<45 yrs old) Pain with intercourse Estrogen/Progesterone sensitive Cancer TOTAL SCORE: GRAND TOTAL SCORE: Are you completely satisfied with your sexual experience: Yes____ No ____ Please explain: Name Date Men Only Yes No Yes No Breast lump – did your mother take it during pregnancy? Lump in testicle Date of last genital exam: Penis discharge Date of last prostate exam: Sore on the penis Date of last test: Result: Erection difficulties Male Hormone Imbalance Rating Please rate the severity of the symptom(s) or condition when it’s present by rating it on a Wellness Gauge Scale 0 to 10, when 0= symptom is not present , 10= symptom is severe Abdominal pain Thinning armpit, head, pubic hair Urine flow dribbling at the end Joint pain/Stiffness Skin problems/dryness Blood in urine Anger easily Excessive sweating (day or night) Urinary incontinence Back pain Mood swings Pain with urination Rheumatoid arthritis Lack interest in leisure/social Pain with ejaculation activities Chronic stress Low stamina Bloody ejaculation Depression Difficulty obtaining erection Pain with intercourse Disinterest in sex/low sex drive Difficulty maintaining erection Unable to conceive (subfertility) Erectile dysfunction Pain with erection Mass in genital organs Fatigue Lack of nocturnal erections Heavy drinking (past/ present) Insomnia Lack of morning erections Frequent urination
Past or Present Condition (0 = none, 10 = yes) Ovarian Cancer Infertility (never able to conceive) Uterine Cancer Loss of height/ bone loss Cervical Cancer Miscarriage Breast Cancer Premature menopause (<45 yrs old) Estrogen/Progesterone sensitive Cancer Pain with intercourse TOTAL SCORE: GRAND TOTAL SCORE: Are you completely satisfied with your sexual experience: Yes____ No ____ Please explain: Name Date Men Only Yes No Yes No Breast lump – did your mother take it during pregnancy? Lump in testicle Date of last genital exam: Penis discharge Date of last prostate exam: Sore on the penis Date of last test: Result: Erection difficulties Male Hormone Imbalance Rating Please rate the severity of the symptom(s) or condition when it’s present by rating it on a Wellness Gauge Scale 0 to 10, when 0= symptom is not present , 10= symptom is severe Abdominal pain Thinning armpit, head, pubic hair Urine flow dribbling at the end Joint pain/Stiffness Skin problems/dryness Blood in urine Anger easily Excessive sweating (day or night) Urinary incontinence Back pain Mood swings Pain with urination Rheumatoid arthritis Lack interest in leisure/social activities Pain with ejaculation Chronic stress Low stamina Bloody ejaculation Depression Difficulty obtaining erection Pain with intercourse Disinterest in sex/low sex drive Difficulty maintaining erection Unable to conceive (subfertility) Erectile dysfunction Pain with erection Mass in genital organs Fatigue Lack of nocturnal erections Heavy drinking (past/ present) Insomnia Lack of morning erections Frequent urination