Health Assessment for MEN
please check 1 box
Email address *
Patient Name: *
Your answer
Patient Phone Number *
Your answer
Fatigue *
Mood Changes *
(irritability, anxiety/nervousness, depression)
Decreased Mental Ability *
(memory loss, confusion, loss of focus)
Excessive Sweating *
Weight Gain *
(bloating, excessive belly fat, inability to lose weight)
Decreased Sex Drive *
(no morning erections)
Sleep Problems *
(can't stay sleep, can't fall asleep)
Decreased Muscle Strength *
Hair Loss / Breakage *
Joint Pain / Muscle Aches *
Family History (check all that apply) *
Required
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