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LIFE ENHANCEMENT CLINICS OF MONTANA
Your Destination for Renewed Vitality!
Male Symptoms Checklist
(Evexias)
First Name
*
Last Name
*
Phone
*
Decline in your feeling of general well-being (general state of health, subjective feeling)
*
None
Mild
Moderate
Severe
Extremely Severe
Joint pain & muscle ache (lower back pain, joint pain, pain in a limb, general back ache)
*
None
Mild
Moderate
Severe
Extremely Severe
Joint & Muscle
Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain)
*
None
Mild
Moderate
Severe
Extremely Severe
Sleeping Problems (difficulty in falling asleep, difficulty in sleelping thru the night, waking up early)
*
None
Mild
Moderate
Severe
Extremely Severe
Sleep
Increased need for sleep, often feeling tired
*
None
Mild
Moderate
Severe
Extremely Severe
Sleep
Irritability (feeling aggressive, easily upset about little things, moody)
*
None
Mild
Moderate
Severe
Extremely Severe
Irritability
Nervousness (inner tension, restlessness, feeling fidgety)
*
None
Mild
Moderate
Severe
Extremely Severe
Irritability
Anxiety (inner restlessness, feeling panicky)
*
None
Mild
Moderate
Severe
Extremely Severe
Anxiety
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)
*
None
Mild
Moderate
Severe
Extremely Severe
Exhaustion
Decrease in muscular strength (feeling of weakness)
*
None
Mild
Moderate
Severe
Extremely Severe
Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use)
*
None
Mild
Moderate
Severe
Extremely Severe
Mood
Feeling that you have passed your peak/prime
*
None
Mild
Moderate
Severe
Extremely Severe
Feeling burnt out, having hit rock-bottom
*
None
Mild
Moderate
Severe
Extremely Severe
Decrease in beard growth
*
None
Mild
Moderate
Severe
Extremely Severe
Decrease in ability/fequency to perform sexually
*
None
Mild
Moderate
Severe
Extremely Severe
Sexual Health
Decrease in the number of morning erections
*
None
Mild
Moderate
Severe
Extremely Severe
Sexual Health
Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)
*
None
Mild
Moderate
Severe
Extremely Severe
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?
Most Recent PSA
Do you have a history of Prostate problems or biopsy performed? If so, please provide details
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