• Men's Hormone Imbalances Assessment

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  • For each of these symptoms that you may experience or have been diagnosed with, rate each accordingly:

    no symptoms    mild      moderate      severe

  • Anxiety
  • Arthritis
  • Bladder symptoms
  • Cold hands and feet
  • Constipation
  • Decreased enjoyment of life
  • Decreased immunity / recovery
  • Decreased strength or endurance
  • Decreased sex drive
  • Decreased ability to play sport
  • Decrease in work performance
  • Depression
  • Dry skin/ hair
  • Elevated LDL cholesterol
  • Erectile dysfunction
  • Fatigue
  • Fluid retention
  • Harder to reach climax
  • Hair loss
  • Headaches
  • Hoarseness (unexplained)
  • Irritability
  • Loss of memory
  • Loose stools
  • Low blood pressure
  • Muscle problems (pain, burning)
  • Night sweats
  • Mood swings
  • Sleep disturbance
  • Weakness/ muscular
  • Weight gain
  • Weight loss
  • Should be Empty: