Male Hormone Questionnaire
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- Sylvia Byrd
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1 Male Hormone Questionnaire ANDROPAUSE QUIZ Are You Suffering from Low Testosterone? Please consider how you feel now and compare that to how you felt in your mid thirties. 0: Normal or unchanged 1: A mild, but noticeable difference 2: A moderate or significant 3: Severe or marked Mental Function Feeling stressed or "burned" out Increased fat in the chest or hip area History of heavy drinking Feeling depressed or negative Feeling irritable or angry Feeling anxious or nervous Feeling mentally fatigued, unable to concentrate Decreased mental sharpness, wit, attention Forgetful, poor memory Decreased assertiveness and/or competitiveness Loss of motivation or initiative to start new projects, participate in hobbies Feeling that work, relationships and hobbies have lost significance Musculo-skeletal System Fatigue or loss of energy particularly in the afternoon and evening Feeling sore all over, aches in joints and muscles Frequent back or neck pain Decrease in physical stamina or endurance Decrease or less than optimal muscle size, tone and strength Decrease in athletic performance; loss of agility, quickness Decline in flexibility and mobility Difficulty in recovering from physical exercise Increased tendency toward muscle pulls or leg cramps Osteoporosis Physical Problems Shortness of breath with activities, worsening of asthma or emphysema Lightheadedness, dizzy spells, ringing in the ears or frequent headaches Poor circulation in legs, swelled ankles, varicose veins or hemorrhoids Changes in visual acuity, ability to read fine print Dry skin on face or hands Excessive sweating during the day or night Urinary frequency, reduced flow or force of flow Metabolic Disease Increase in total cholesterol or triglycerides Decrease in HDL cholesterol Onset of high blood sugar, insulin or diabetes Rise in blood pressure, onset of hypertension Development of chest pain, heart disease, blocked arteries Unexplained weight gain, particularly In the midsection Enlarged prostate or increased PSA Loss of body hair, axillary hair, decreased need to shave as frequently Sexual Function Decrease in spontaneous early morning erections Decreased libido or desire for sex* Decrease in fullness of erection* Decreased volume or strength of force of climax Difficulty in maintaining full erection Difficulty in achieving an erection TOTAL TESTOSTERONE SCORE (0-5-unlikely; 6-10 possible; 10+ probable) You are at moderate risk for low testosterone levels if you answer yes to anyone of the questions below. I have a history of adult mumps, orchitis or other testicular problems I have had a prostate operation or persistent inflammation / infection of the prostate I have had a vasectomy Repeated use of prednisone, inhaled steroids Use of Proscar, Propecia Prior use of anabolic steroids, pro-hormones Use of "statins", chronic anti-fungals, anti-convulsants, Amiodarone, thiazide diuretics propylthiouracil, cancer chemotherapy Smoke more than 1pack of cigarettes per day Drink alcohol regularly, occasionally to excess More than 20 pounds overweight Have used Marijuana or other recreational drugs regularly In the past Testosterone Score Overview The decline in testosterone may be subtle but is rarely accompanied by only one symptom severely. Rather it affects all the tissues that contain testosterone receptors, which is the whole body. A sudden loss of erectile capacity by itself is not likely to be due to a sudden testosterone deficiency. Likewise, the development of one symptom or another alone is not a red flag for the"male Menopause". Usually, decline in testosterone is gradual with a slow steady accompaniment of systemic symptoms that creep in like a "thief in the night. Changes in energy, desire for usual activities, interest in sex, soreness and stiffness together are strong signals of change in testosterone, but require testing to confirm the status of the androgen hormones. (* if both are positive deficiency likely) A New Leaf Nutrition Last updated February 22, 2018 Page 1
2 H ORMONE BALANCE QUESTIONNAIRE FOR MEN Name: Date: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Age: Height: Weight: Primary Care Doctor: HEALTH HISTORY Do you have a personal or family history of any of the following? Prostate Cancer Breast Cancer Osteoporosis Have you had any of the following tests? PSA No Yes ( Date) Abnormal? No Yes DEXA Scan (Bone Density - Screen for Osteoporosis) No Yes ( Date) Abnormal? No Yes Colonoscopy No Yes ( Date) Abnormal? No Yes MEDICAL CONDITIONS / DISEASES (please check all that apply) Heart Disease (heart attack, CHF, etc.) High Cholesterol High Blood Pressure Cancer (type ) Ulcers (stomach, esophagus) Thyroid Problems Hormone Related Issues Lung Problems (asthma, COPD, etc.) Blood Clotting Problems o Diabetes Arthritis or Joint Problems o Depression Epilepsy or Seizure Disorder Headaches / Migraines Eye Disease (glaucoma, etc.) Liver or Gastrointestinal Disorder Other (please explain) A New Leaf Nutrition Last updated February 22, 2018 Page 2
3 PREVIOUS SURGERIES / HOSPITALIZATIONS (please list) Have you had prostate surgery? No Yes (date of surgery) Please list any other surgeries you have had: LIFESTYLE Do you smoke? Do you drink alcohol? Do you use recreational drugs? Do you exercise? ALLERGIES / MEDICATION INTOLERANCES (please list) I have no allergies or medication intolerances that I know of. MEDICATIONS Current Prescriptions and Over-the-Counter Medications List Hormones Currently or Previously Taken A New Leaf Nutrition Last updated February 22, 2018 Page 3
4 NUTRITIONAL SUPPLEMENTS (please circle the product you are using): Vitamins (multiple or single vitamins such as B complex, E, C, D, beta carotene, other) Minerals (calcium, magnesium, chromium, iron, zinc, copper, other) Herbs (ginseng, gingko biloba, Echinacea, medicinal teas, other) Enzymes (Digestive, papaya, bromelain, CoQlO, other) Nutritional / Protein Supplements (shark cartilage, protein powders, amino acids, fish / flaxseed oil, other) Other (please list) I do not take any nutritional supplements CURRENT SYMPTOMS For each item identified below, circle the number that best fits the symptoms you are experiencing. 0 = none 1 = mild 2 = moderate 3 = severe Decreased Muscle Mass Reduced Energy Weight Gain Loss of Sex Drive Difficulty Falling Asleep Erectile Dysfunction Difficulty Staying Asleep Urinary Problems Morning Fatigue Urinary Tract Infections Evening Fatigue Urinary Incontinence Depression Thinning Skin Anxiety Oily Skin Irritable Weight Gain - Hips Memory Lapses Weight Gain - Waist Tearfulness Decreased Muscle Mass Foggy Thinking Sugar / Carb Cravings Stress Unusual Sweating Hair Loss on Scalp Hoarseness Increased Facial of Body Hair Bulging Eyes Dry / Brittle Hair Slowed Reflexes Dry / Brittle Nails Cold Body Temperature Acne Blood Pressure Problems A New Leaf Nutrition Last updated February 22, 2018 Page 4
5 DO YOU FEEL LIKE A SHADOW OF YOUR FORMER SELF? Take the Low T (testosterone) quiz*. Yes No 1. Do you have a decrease in libido (sex drive)? 2. Do you have a lack of energy? 3. Do you have a decrease in strength and/or endurance? 4. Have you lost height? 5. Have you noticed a decreased "enjoyment of life"? 6. Are you sad and/or grumpy? 7. Are your erections less strong? 8. Have you noticed a recent deterioration in your ability to play sports? 9. Are you falling asleep after dinner? 10. Has there been a recent deterioration in your work performance? A New Leaf Nutrition Last updated February 22, 2018 Page 5
HORMONE BALANCE QUESTIONNAIRE FOR MEN
HORMONE BALANCE QUESTIONNAIRE FOR MEN Name: Date: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Age: Height: Weight: Primary Care Doctor: Health History Do you have a personal
HORMONE BALANCE QUESTIONNAIRE FOR WOMEN
HORMONE BALANCE QUESTIONNAIRE FOR WOMEN Name: Date: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Age: Height: Weight: Primary Care Doctor: Health History Do you have a
Male New Patient Questionnaire
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Medical Health Questionnaire
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TEST REPORT # SB. Patient Name: Comprehensive Male Profile I Patient Phone Number: TEST NAME RESULTS 08/12/18 RANGE
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Name: Date of Birth: Age: Address: City State Zip
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THE MANY SYMPTOMS ROOTED IN HORMONE IMBALANCES
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You may also fax, , or bring it to office ahead of time, but please bring another paper copy with you at the time of visit.
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Check this list for all conditions that apply to you. The total possible score is 209. Count the number of symptoms you check. The higher your score, the more likely you need to address hormone imbalances.
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Accession #: Patient: Jane Doe Convert to pdf, Save or PRINT >> ADRENAL CHECK
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1 How do you diagnose low Testosterone in men? Low Testosterone can be diagnosed if you have 3 or more of the following symptoms: lack of libido fatigue insomnia erectile dysfunction (ED) depression loss
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MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
Men s Health Hormone Self-Assessment
Page 1 of 5 12/2016 Consulting Pharmacist: _Consultation Date: How did you hear about College Pharmacy s & Consultation Services? Advertisement Another Patient Healthcare Provider Books/Articles Website
SLEEP QUESTIONNAIRE. Name: Home Telephone. Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: Pharmacy & Phone #:
q JHMCE q JHS q SMEH SLEEP QUESTIONNAIRE 1. DEMOGRAPHIC DATA Name: Home Telephone Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: 2. PHYSICIAN INFORMATION Name of Primary
Patient Health History
Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Phone: Email: Children (quantity/age): Mailing Address: 1. Please identify the
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
TOUCHMATTERS MANUAL THERAPY Health History Form NAME: DATE: ADDRESS: (street and number) (city) (postal code) TELEPHONE: (home) (work) (cell)
TOUCHMATTERS MANUAL THERAPY Health History Form The information that you are providing on this form will give me the necessary starting point to help you with your primary complaint. Please be as thorough
MICRO SAMPLE ASSAYS Result Range Units
P: 1300 688 522 E: info@nutripath.com.au A: PO Box 442 Ashburton VIC 3142 TEST PATIENT Sex : D Collected : 00-00-0000 111 ROAD TEST SUBURB AB : 00000000 UR:0000000 TEST PHYSICIAN DR JOHN DOE 111 CLINIC
Pure Health Natural Medicine
Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell