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Hormone Assessment

Male Hormone Self-Assessment Test

YOU CAN IMPROVE YOUR HORMONAL HEALTH?
Check any of the following statements that apply to you.

Date:
First Name:
Last Name:
Age:
Email:

Do You...
	Have a history of antibiotic use
	Continuously use prescription medication
	Take synthetic hormones in topical cream, patch or orally
	Have prostate problems
	Experience difficulty sleeping
	Experience mood swings
	Experience low libido
	Drink more than one glass of alcohol weekly
	Drink caffeine daily
	Experience Exhaustion
	Experience low sperm count
	Experience penile erectile dysfunction
	Experience infertility
	Experience frequent urination

Male Reproductive
Do You Have...
	Prostate trouble
	Urination difficult or dribbling
	Night urination frequent
	Pain on inside of legs or heels
	Feeling of incomplete bowel evacuation
	Leg nervousness at night
	Tire easily/avoid activity
	Reduced sex drive
	Depression
	Migrating aches and pains
	Frequent or urgent need to urinate
	Delayed, weak or interrupted urinary stream
	Pain or burning upon urination
	Urge to urinate several times a night
	Rose colored (bloody) urine
	Difficulty urinating
	A sense of bladder fullness
	Ejaculation causes pain
	Blood in the semen
	Lack of sex drive
	Impotency
	Pain or fatigue in the legs or back
	Dripping after urination
	Increased straining with small amounts of urine passed
	Anemia
	Current prostate enlargement or elevated PSA (prostate) test

Male Genital Health
Do You Have...
	Itchy patches around inner thigh or groin
	Itching at night
	Painful testicles
	Difficulty attaining and or maintaining an erection
	Low sexual drive
	Premature Ejaculation
	Low energy level or stamina
	Inflammation on the head of the penis
	Genital and/or rectal rash or irritation
	Distorted nail growth
	Loss of pubic or armpit hair
	Infertile
	Low sperm count, low sperm motility
	Unexplained weight gain
	Testicles appear smaller
	Development of breasts or nipple tenderness
	Feeling of heaviness or hardness in testicles
	Sparse beard or slow hair growth
	Decreased body hair
	Fine wrinkling in corner of mouth and/or eyes
	Current or recurrent epididimiti

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