HORMONE BALANCE QUESTIONNAIRE FOR MEN

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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 or family history of any of the following? Prostate Cancer No Yes (relationship) Breast Cancer No Yes (relationship) Osteoporosis No Yes (relationship) 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 Diabetes Arthritis or Joint Problems Depression Epilepsy or Seizure Disorder Headaches / Migraines Eye Disease (glaucoma, etc.) Liver or Gastrointestinal Disorder Other (please explain) 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? Yes No (details) _ Do you drink alcohol? Yes No (details) _ Do you use recreational drugs? Yes No (details) _ Do you exercise? Yes No (details) _ 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

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, CoQ10, 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 0 1 2 3 Reduced Energy 0 1 2 3 Weight Gain 0 1 2 3 Loss of Sex Drive 0 1 2 3 Difficulty Falling Asleep 0 1 2 3 Erectile Dysfunction 0 1 2 3 Difficulty Staying Asleep 0 1 2 3 Urinary Problems 0 1 2 3 Morning Fatigue 0 1 2 3 Urinary Tract Infections 0 1 2 3 Evening Fatigue 0 1 2 3 Urinary Incontinence 0 1 2 3

Depression 0 1 2 3 Thinning Skin 0 1 2 3 Anxiety 0 1 2 3 Oily Skin 0 1 2 3 Irritable 0 1 2 3 Weight Gain - Hips 0 1 2 3 Memory Lapses 0 1 2 3 Weight Gain - Waist 0 1 2 3 Tearfulness 0 1 2 3 Decreased Muscle Mass 0 1 2 3 Foggy Thinking 0 1 2 3 Sugar / Carb Cravings 0 1 2 3 Stress 0 1 2 3 Unusual Sweating 0 1 2 3 Hair Loss on Scalp 0 1 2 3 Hoarseness 0 1 2 3 Increased Facial or Body Hair 0 1 2 3 Bulging Eyes 0 1 2 3 Dry / Brittle Hair 0 1 2 3 Slowed Reflexes 0 1 2 3 Dry / Brittle Nails 0 1 2 3 Cold Body Temperature 0 1 2 3 Acne 0 1 2 3 Blood Pressure Problems 0 1 2 3 What are your goals with Bioidentical Hormone Replacement Therapy (BHRT)? Please write down any questions you have about BHRT: Patient Signature Date

Do you feel like a shadow of your former self? Take the Low T (testosterone) quiz*. Healthcare providers weigh a lot of factors when diagnosing hypogonadism, a medical condition caused by Low T. They include medical history and exam including clinical signs and symptoms and certain blood tests. This checklist is a starting point to help identify what to look for and can help you have a productive conversation with your healthcare provider. 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? If you answered yes to question 1 or 7, or any other 3 questions, ask your healthcare provider if you could have a medical condition caused by Low T and if you should be tested.

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