Health Assessment for Men

Men's Health Assessment
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number

Area CodePhone Number
Symptoms

Please rate each symptom below as: Never, Mild, Moderate, or Severe
1) Sweating (night sweats or excessive sweating)
2) Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)
3) Increased need for sleep or falls asleep easily after a meal
4) Depressive mood (feeling down, sad, lack of drive or interest, loss of "zest for life")
5) Irritability (mood swings, feeling aggressive, angers easily)
6) Anxiety (feeling overwhelmed, inner restlessness, feeling panicked, feeling nervous, inner tension)
7) Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)
8) Sexual problems (change in sexual desire or in sexual performance)
9) Bladder problems (difficulty in urinating, increased need to urinate)
10) Erectile changes (weaker erections, loss of morning erections)
11) Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise, inability to add muscle)
12) Difficulties with memory (concentration, finding the right word, or retaining information)
13) Problems with thinking, concentrating, or reasoning
14) Difficulty learning new things
15) Trouble thinking of the right word to describe persons, places, or things when speaking
16) Increase in frequency or intensity of headaches/migraines
17) Rapid hair loss or thinning
18) Feel cold all the time or have cold hands or feet
19) Weight gain, increased belly fat, or difficulty losing weight despite diet and exercising
20) Infrequent or absent ejaculations
Severity Score
Severity score: Mild:1-20 / Moderate 21-40 / Severe 41-60 / Very Severe 61-80
Family History
Family History of Heart Disease
Family History of Diabetes
Family History of Osteoporosis
Family History of Alzheimer’s Disease
Family History of Prostate Cancer
Do any of these apply to you?
Currently trying to conceive?
Currently on testosterone therapy?
If yes, list name and dose of hormone(s)
Are you on any testosterone boosting medication (Clomid, HCG, etc.)?
Currently on a 5a reductase inhibitor medication (see list below)?
Proscar (Finasteride), Avodart (Dutasteride), Jalyn (Dutasteride/Tamsulosin), Propecia (Finasteride)
Are you on PDE-5 Inhibitor (Cialis, Viagra, Etc.)
Have prostate cancer?
Have Hashimoto's thyroiditis?
Are you a smoker?
Are you currently on Thyroid medication?
Are you currently on oral nitrates?
Are you currently on Statins?
What is your activity level?
What is your current weight?
The Sexual Health Inventory for Men (SHIM) Questionnaire

Over the past 6 months...
How would you rate your confidence that you could get and keep an erection?
When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
When you attempted sexual intercourse, how often was it satisfactory for you?
Calculation
Should be Empty:

Men's Health Assessment

Symptoms

Family History

Do any of these apply to you?

The Sexual Health Inventory for Men (SHIM) Questionnaire