Male Hormone Replacement Therapy

First Name *

Last Name *

Phone *

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

Sleeping Problems (difficulty in falling asleep, difficulty in sleelping thru the night, waking up early) *Sleep

Physical exhaustion / lacking vitality (general decrease in performance, reduced activity , lacking interest in leisure activities, feeling of getting less done, of achieving less, of having to force oneself to undertake activities) *Exhaustion

Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use) *Mood

Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse) *Sexual Health

Please share any additional comments about your symptoms you would like to address.

Do you have cold hands and feet? *

Yes

No

Do you have daily bowel movements? *

Yes

No

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

Yes

No

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

0-1 days/week (low)

2-3 days/week (average)

More than 3 days/week (high)

Please list any prior hormone therapy?

LIFE ENHANCEMENT CLINICS OF MONTANA

Your Destination for Renewed Vitality!

Male Symptoms Checklist

(Evexias)