Please select your biological sex *

Female

Male

Please rate each of the following symptoms based on how you are currently experiencing them.

Mark only one option per symptom.
If a symptom does not apply to you, select “None.”

Hot flashes, sweating (episodes of sweating) *

Heart discomfort (unusual awareness of heartbeat, heart skipping, heart racing, tightness) *

Sleep problems (difficulty falling asleep, trouble sleeping through the night, or waking up early) *

Depressive mood (feeling down, sad, on the verge of tears, lack of drive, or mood swings) *

Irritability (feeling nervous, inner tension, or aggressive) *

Anxiety (inner restlessness or feeling panicky) *

Physical and mental exhaustion (general decrease in performance, impaired memory, poor concentration, or forgetfulness) *

Sexual problems (change in sexual desire, activity, or satisfaction) *

Bladder problems (difficulty urinating, increased urgency, or bladder incontinence) *

Vaginal dryness (sensation of dryness or burning in the vagina, or difficulty with sexual intercourse) *

Joint and muscular discomfort (joint pain or rheumatoid-type symptoms) *

Decline in your feeling of general well-being (general state of health, subjective feeling) *

Joint pain and muscular ache (e.g., lower back pain, joint pain, limb pain, general backache)

Excessive sweating (unexpected or sudden episodes of sweating, hot flushes not caused by activity)

Sleep problems (difficulty falling asleep, staying asleep, waking up early, poor quality sleep)

Increased need for sleep; often feeling tired

Irritability (feeling aggressive, moody, easily upset by small things)

Nervousness (inner tension, restlessness, and/or fidgeting)

Anxiety (feeling panicky)

Physical exhaustion / lack of vitality (reduced performance or activity, disinterest in hobbies, feeling unproductive)

Decrease in muscular strength (feeling weak or less strong than usual)

Depressive mood (feeling down, sad, low motivation, mood swings, hopelessness)

Feeling that you have passed your peak

Feeling burnt out or like you’ve hit rock bottom

Decrease in beard growth

Decrease in sexual performance or frequency

Decrease in number of morning erections

Decrease in sexual desire/libido (less pleasure or interest in sex)

Please share any additional comments about your symptoms you'd like to address. *

Do you have cold hands and feet? *

Yes

Do you have daily bowel movements? *

Yes

Do you have gas, bloating or abdominal pain after eating? *

Yes

Please select your WEEKLY Activity Level based on this criteria (Physical activity that accelerates heart rate / Breathlessness) *

0-1 day per week (Low)

2-3 days per week (Average)

More than 3 days per week (High)

Please list any prior hormone therapy?

Recent PSA (Prostate-Specific Antigen) Test Result:

Recent Digital Rectal Exam (Date):

Was the exam normal or abnormal?

History of prostate problems or biopsy?

Yes

If yes, please provide details:

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