Male Checklist

Date

Name

Phone Number

Email Address

Declined In Well Being Declined In Well Being Never Mild Moderate Severe

Fatigue Fatigue Never Mild Moderate Severe

Joint Pain/Muscle Ache Joint Pain/Muscle Ache Never Mild Moderate Severe

Excessive Sweating Excessive Sweating Never Mild Moderate Severe

Increased Need For Sleep Increased Need For Sleep Never Mild Moderate Severe

Sleep Problems Sleep Problems Never Mild Moderate Severe

Irritability Irritability Never Mild Moderate Severe

Nervousness Nervousness Never Mild Moderate Severe

Anxiety Anxiety Never Mild Moderate Severe

Depressed Mood Depressed Mood Never Mild Moderate Severe

Exhaustion/Lacking Vitality Exhaustion/Lacking Vitality Never Mild Moderate Severe

Declining Mental Ability/Focus/Concentration Declining Mental Ability/Focus/Concentration Never Mild Moderate Severe

Feeling Like You Have Passed Your Peak Feeling Like You Have Passed Your Peak Never Mild Moderate Severe

Feeling Burned Out/Hit Rock Bottom Feeling Burned Out/Hit Rock Bottom Never Mild Moderate Severe

Decreased Muscle Strength Decreased Muscle Strength Never Mild Moderate Severe

Weight Gain/Belly Fat/Inability to lose Weight Weight Gain/Belly Fat/Inability to lose Weight Never Mild Moderate Severe

Breast Development Breast Development Never Mild Moderate Severe

Shrinking Testicles Shrinking Testicles Never Mild Moderate Severe

Rapid Hair Loss Rapid Hair Loss Never Mild Moderate Severe

Decreased Beard Growth Decreased Beard Growth Never Mild Moderate Severe

New Migraine Headaches New Migraine Headaches Never Mild Moderate Severe

Decreased Sexual Desire/Libido Decreased Sexual Desire/Libido Never Mild Moderate Severe

Decreased Morning Erections Decreased Morning Erections Never Mild Moderate Severe

Decreased Ability To Preform Sexually Decreased Ability To Preform Sexually Never Mild Moderate Severe

Infrequent Or Absent Ejaculations Infrequent Or Absent Ejaculations Never Mild Moderate Severe

No Results From E.D. Medications No Results From E.D. Medications Never Mild Moderate Severe