Fatigue *

Never

Mild

Moderate

Severe

Memory Loss *

Never

Mild

Moderate

Severe

Mental Confusion *

Never

Mild

Moderate

Severe

Decreased Sex Drive or Libido *

Never

Mild

Moderate

Severe

Sleep Problems *

Never

Mild

Moderate

Severe

Mood Change *

Never

Mild

Moderate

Severe

Tension *

Never

Mild

Moderate

Severe

Migraines or Severe Headaches *

Never

Mild

Moderate

Severe

Difficult to Climax Sexually *

Never

Mild

Moderate

Severe

Bloating *

Never

Mild

Moderate

Severe

Weight Gain *

Never

Mild

Moderate

Severe

Breast Tenderness *

Never

Mild

Moderate

Severe

Vaginal Dryness *

Never

Mild

Moderate

Severe

Hot Flashes *

Never

Mild

Moderate

Severe

Night Sweats *

Never

Mild

Moderate

Severe

Dry or Wrinkled Skin *

Never

Mild

Moderate

Severe

Hair Falling Out *

Never

Mild

Moderate

Severe

Cold All The Time *

Never

Mild

Moderate

Severe

Swelling All Over The Body *

Never

Mild

Moderate

Severe

Joint Pain *

Never

Mild

Moderate

Severe

Name *

First Name

Last Name

Phone *

(###)

###

####

Decline in General Well Being *

Never

Mild

Moderate

Severe

Fatigue *

Never

Mild

Moderate

Severe

Joint Pain *

Never

Mild

Moderate

Severe

Excessive Sweating *

Never

Mild

Moderate

Severe

Sleep Problems *

Never

Mild

Moderate

Severe

Irritability *

Never

Mild

Moderate

Severe

Nervousness or Anxiety *

Never

Mild

Moderate

Severe

Depressed Mood *

Never

Mild

Moderate

Severe

Exhaustion & Lacking Vitality *

Never

Mild

Moderate

Severe

Declining Mental Focus & Concentration *

Never

Mild

Moderate

Severe

Feeling You Have Passed Your Peak *

Never

Mild

Moderate

Severe

Feeling Burned Out *

Never

Mild

Moderate

Severe

Decreased Muscle Strength *

Never

Mild

Moderate

Severe

Weight Gain, Belly Fat, or Unable to Lose Weight *

Never

Mild

Moderate

Severe

Shrinking Testicles *

Never

Mild

Moderate

Severe

Rapid Hair Loss *

Never

Mild

Moderate

Severe

Breast Development *

Never

Mild

Moderate

Severe

Decrease in Beard Growth *

Never

Mild

Moderate

Severe

Migraine Headaches *

Never

Mild

Moderate

Severe

Decreased Sexual Desire or Libido *

Never

Mild

Moderate

Severe

Decreased Morning Erections *

Never

Mild

Moderate

Severe

Decreased Ability to Perform Sexually *

Never

Mild

Moderate

Severe

Infrequent or Absent Ejaculations *

Never

Mild

Moderate

Severe

Name *

First Name

Last Name

Phone *

(###)

###

####