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MEN’S HORMONE QUESTIONAIRE
Men Hormone Survey
First Name
Last Name
Email
Phone Number
Age
Sleep Disturbance
Insomnia:
Not a problem
Sometimes
Frequent
Disruption:
Not a problem
Sometimes
Frequent
Cognitive Changes
Focus:
No changes
Sometimes
Frequent
Forgetful:
No changes
Sometimes
Frequent
Foggy:
No changes
Sometimes
Frequent
Temperature Change
Cold:
No change
Sometimes
Always
Hot:
No change
Sometimes
Frequent
Hot Flashes / Sweats
Hot Flashes / Sweats:
Non-existent
Sometimes
Frequent
Headaches
Frequency:
Not a problem
Sometimes
Often
Severity:
Not a problem
Slight pain
Severe pain
Mood Change
Motivation / Satisfaction:
No change
Sometimes low
Always low
Irritability:
Not irritable
Sometimes
Always
Tearfulness:
Not tearfulness
Sometimes
Frequent
Anxiety:
No anxiety
Sometimes
Frequent
Worn Down:
No change
Slight problem
Problem
Fatigue/Decreased Energy
Fatigue/Decreased Energy:
No change
Sometimes
Always
Weight Gain
Weight Gain:
Yes
No
Abdominal Mass Increase:
Yes
No
Dieting Results:
No dieting
Some results
No results
Sexual Function
Decreased Libido:
No change
Decreased
No libido
Problems Maintaining Erection:
No change
More difficult
Cannot achieve
Breast Tenderness
Breast Sensitivity:
Yes
No
Nodule Sensitivity:
Yes
No
Bladder
Frequency/Urgency:
No change
Sometimes
Always
Leaking/Stress Incontinence:
Not occurring
Sometimes occurring
Frequently occurring
Hair/Skin
Body Hair:
No
Some
Noticeable Increase
Hair Dryness:
No
Some
Very dry
Hair Brittleness:
No
Notice difference
Frequent breaking
Hair Loss:
No loss
Some loss
Large amount
Skin Dryness:
No
Some
Very dry
Weight Loss
Of Diet:
No change
Slight decrease
Noticeable decrease
On Diet:
No change
Slight decrease
Noticeable decrease
Muscle Loss
Mass:
No change
Slight decrease
Noticeable decrease
Tone:
No change
Slight change
Noticeable change
Strength:
No change
Slight change
Noticeable change
Cellulite:
No change
Slight change
Noticeable change
Chronic Pain
Arthritis:
Yes
No
Stiffness:
Yes
No
Soreness:
Yes
No
Achiness:
Yes
No
Injury:
Yes
No
Heartburn
Heartburn:
Yes
No
Cardiac Changes
Shortness of Breath:
Yes
No
Chest Pain:
Yes
No
Flutters/Palpitations:
Yes
No
Decreased Exercise Tolerance:
Yes
No
Diagnosed Heart Condition:
Yes
No
Body Oder Changes
Body Oder Changes:
Yes
No
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