TRT Questionnaire - Rejuv Medical Louisville
Which of the following symptoms apply to you at this time? Please, mark the appropriate box for each symptom. For symptoms that do not apply, please mark "none".
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Are you a new or existing customer? *
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Your name: *
Phone number: *
Email: *
1. Decline in your feeling of general well-being (general state of health, subjective feeling).... *
None
Extremely Severe
2. Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache).... *
None
Extremely Severe
3. Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain).... *
None
Extremely Severe
4. Sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness).... *
None
Extremely Severe
5. Increased need for sleep, often feeling tired..... *
None
Extremely Severe
6. Irritability (feeling aggressive, easily upset about little things, moody)..... *
None
Extremely Severe
7. Nervousness (inner tension, restlessness, feeling fidgety)... *
None
Extremely Severe
8. Anxiety (feeling panicky)..... *
None
Extremely Severe
9. Physical exhaustion / lacking vitality (general decrease in performance, reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, of having to force oneself to undertake activities).... *
None
Extremely Severe
10. Decrease in muscular strength (feeling of weakness).... *
None
Extremely Severe
11. Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use).... *
None
Extremely Severe
12. Feeling that you have passed your peak.... *
None
Extremely Severe
13. Feeling burnt out, having hit rock-bottom.... *
None
Extremely Severe
14. Decrease in beard growth.... *
None
Extremely Severe
15. Decrease in ability/frequency to perform sexually.... *
None
Extremely Severe
16. Decrease in the number of morning erections.... *
None
Extremely Severe
17. Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse).... *
None
Extremely Severe
Have you got any other major symptoms? *
If Yes, please describe:
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