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Night Sweats AbsentMildModerateSevere
Insomnia AbsentMildModerateSevere
Acne AbsentMildModerateSevere
Mood Swings AbsentMildModerateSevere
Decreased Muscle Mass AbsentMildModerateSevere
Headaches AbsentMildModerateSevere
Anxiety AbsentMildModerateSevere
Depression AbsentMildModerateSevere
Irritability AbsentMildModerateSevere
Fatigue AbsentMildModerateSevere
Forgetfulness AbsentMildModerateSevere
Constipation AbsentMildModerateSevere
Weight Gain AbsentMildModerateSevere
Dry Skin AbsentMildModerateSevere
Hair Loss AbsentMildModerateSevere
Fluid Retention AbsentMildModerateSevere
Brittle Nails AbsentMildModerateSevere
Cold Extremities AbsentMildModerateSevere
Lack of Focus AbsentMildModerateSevere
Heart Palpitations AbsentMildModerateSevere
Hand Tremors AbsentMildModerateSevere
Low Libido AbsentMildModerateSevere
Inability to Climax AbsentMildModerateSevere
Inability to Maintain Erection AbsentMildModerateSevere
Excessive Thrist AbsentMildModerateSevere
Night Time Urination AbsentMildModerateSevere
Are you fasting today? NANoYes
Have you taken your thyroid medication today? NANoYes
Are you on testosterone? NANoYes
Have you exercised today? NANoYes
Greater than 12 hours since last ejaculation? NANoYes
If on testosterone, what date was your last dose taken?
Patient Signature:
Date
PMSPeri-MenopauseMenopause
Pelvic Floor HealthUrinary Incontinence
Hypothyroid & Hashimoto’s Thyroiditis
Anti-AgingAge Management
Women’s Health
PCOS-Polycystic Ovarian Syndrome
Sexual Intimacy
AndopauseMale Menopause
