Male Hormone Screening Self Test

Rate the following as they apply to you.  Use the numbers 1 - 4, with 1 being Rare or Mild, and 4 being Frequent or Severe.

                                                                                                                  Rare            Mild            Frequent            Severe

1.    Fatigue, tiredness or loss of energy                                              1                        2                                  3                               4

2.    Decrease in physical stamina                                                        1                        2                                  3                               4

3.    Feelings of depression - a sense that work, marriage              1                        2                                  3                               4
       or recreational activities have lost significance.

4.    Decreased libido - less desire for sex                                           1                        2                                  3                               4 

5.    Erection or potency problems                                                          1                        2                                  3                               4

6.    Loss of early morning erection                                                        1                        2                                  3                               4

7.    Dry skin on face or hands                                                                 1                        2                                  3                               4

8.    Increase in waist size - weight gain, especially around             1                        2                                  3                               4
       the mid section.

9.    Increased fat distribution in chest area or hips                            1                        2                                  3                               4

10.  Feeling burned out, loss of motivation                                           1                        2                                  3                               4

11.  Increase in aches, joint and muscle pains                                   1                        2                                  3                               4

12.  Frequent use of alcohol - now or in the past                                 1                        2                                  3                               4

13.  Increased irritability, anger or bad temper                                     1                        2                                  3                               4

14.  Decreased in muscle mass                                                             1                        2                                  3                               4

15.  The age you are?

16.  The age you feel?