Men's Health & Vitality Assessment

Mens' Health Assessment

Which of the following symptoms apply to you currently (in the last 2 weeks)? Please make the appropriate selection for each symptom down below. For symptoms that do not currently apply or no longer apply, mark "none".

First Name *
Last Name *

Email *

Phone Number *

Symptoms

Sweating (night sweats or excessive sweating) *

Sleep problems (falling asleep, disturbed sleep) *

Increased need for sleep or falls asleep easily after meal *

Depressive mood (feeling down, sad, lack of drive) *

Irritability (mood swings, feeling aggressive, angers easily) *

Anxiety (inner restlessness, panicked, nervous, inner tension) *

Physical Exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation) *

Sexual Problems (change in sexual desire or performance) *

Bladder Problems (difficulty or increased need to urinate) *

Erectile Changes (loss of morning erections, weaker erections) *

Joint & Muscle Symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise) *

Difficulties with Memory *

Problems with thinking, concentrating, or reasoning *

Difficulty learning new things *

Trouble thinking of right word to describe person/place/things *

Increase in frequency or intensity of headaches/migraines *

Rapid hair loss or thinning *

Feel cold all the time or have cold hands or feet *

Weight gain, increased belly fat, difficulty losing weight despite diet and exercise *

Infrequent or absent ejaculations *

Total Score *

Severity Score: Mild 1-20 / Moderate: 21-40 / Severe: 41-60 / Very Severe: 61-80

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Men's Health & Vitality Assessment

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