Men's Health & Vitality Assessment

Which of the following symptoms apply to you currently (in the last 2 weeks)? Please make the appropriate selection for each symptom down below. For symptoms that do not currently apply or no longer apply, mark "none".

First Name

Last Name

Phone *

Email *

Symptoms

Sweating

Sleep Problems

Increased need for sleep or falls asleep easily after meal

Depressive Mood

Irritability

Anxiety

Physical Exhaustion

Sexual Problems

Bladder Problems

Erectile Changes

Joint and Muscle Symptoms

Difficulties with Memory

Problems with thinking, concentrating, or reasoning

Difficulty learning new things

Trouble thinking or right word to describe person/place/things when speaking

Increase in frequency or intensity of headaches/migraines

Hair loss, thinning or change in texture of hair

Feel cold all the time or have cold hands or feet

Weight gain or difficulty losing weight despite diet/exercise

Note: Please add up your score and enter it below.

Vitality Score: Mild (1-20) / Moderate: (21-40) / Severe (41-60) / Very Severe: (61-80)

Total Score