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Modern Rejuvenation Center
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Home
About Us
Services
Aesthetics
Chemical Peel
Microblading
Microneedling
Body Sculpting
Hormone Therapy
BHRT
Women Hormone Therapy
Mens Hormone Therapy
Functional Medicine
Injectables
Botox
Fillers
Xeomin
Injectable Parties
What is PDO Thread Lift?
Memberships
Shop
Contact Us
Blog
BHRT Symptoms Questionnaire for Men
Step
1
of
3
33%
Sweating (night sweats or excessive sweating)
None
Mild
Moderate
Severe
Very Severe
Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)
None
Mild
Moderate
Severe
Very Severe
Increased need for sleep or falls asleep easily after a meal
None
Mild
Moderate
Severe
Very Severe
Depressive mood (feeling down, sad, lack of drive)
None
Mild
Moderate
Severe
Very Severe
Irritability (mood swings, feeling aggressive, angers easily)
None
Mild
Moderate
Severe
Very Severe
Anxiety (inner restlessness, feeling panicked, feeling nervous, inner tension)
None
Mild
Moderate
Severe
Very Severe
Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina, or motivation)
None
Mild
Moderate
Severe
Very Severe
Sexual problems (change in sexual desire or in sexual performance)
None
Mild
Moderate
Severe
Very Severe
Bladder Problems (difficulty in urinating, increased need to urinate)
None
Mild
Moderate
Severe
Very Severe
Erectile changes (weaker erections, loss of morning erections)
None
Mild
Moderate
Severe
Very Severe
Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)
None
Mild
Moderate
Severe
Very Severe
Difficulties with memory
None
Mild
Moderate
Severe
Very Severe
Problems with thinking, concentrating, or reasoning
None
Mild
Moderate
Severe
Very Severe
Difficulty learning new things
None
Mild
Moderate
Severe
Very Severe
Trouble thinking of the right word to describe persons, places, or things when speaking
None
Mild
Moderate
Severe
Very Severe
Increase in frequency or intensity of headaches/migraines
None
Mild
Moderate
Severe
Very Severe
Rapid hair loss or thinning
None
Mild
Moderate
Severe
Very Severe
Feel cold all the time or have cold hands or feet
None
Mild
Moderate
Severe
Very Severe
Weight gain, increased belly fat, or difficulty losing weight despite diet and exercise
None
Mild
Moderate
Very Severe
Infrequent or absent ejaculations
None
Mild
Moderate
Severe
Very Severe
Date
MM slash DD slash YYYY
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
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