Returning Men's Symptoms Questionnaire

First Name

Last Name

Date of birth

Please fill out the following categories below to let us know how you are feeling at TODAY's appointment.

Progesterone Symptoms

What are your CURRENT symptoms? 0 means you have no symptoms of this type at all. 1 means you have very mild symptoms of this type. 5 would be moderate symptoms and 10 would mean you have severe symptoms of this type.

Sleep Disturbances

Depression

Irritability

Anxiety

Restless Legs Syndrome

Mood Swings

Migraine Headaches

Palpitations

Estrogen Symptoms

Night Sweats

Hot Flashes

Dry Skin

Testosterone Symptoms

Fatigue

Low Sex Drive

Erectile Dysfunction

Poor Focus

Body & Joint Pain

Memory Lapses

Low Exercise Tolerance

Loss of Muscle Tone

Acne

Facial/Body Hair

Patient comments or any changes in medical conditions or medications since last report:

I certify I have answered the questions to the best of my ability to help my healthcare provider address my needs.

Today's Date