Health Assessment Form
Instructions:
Which of the following symptoms have you been experiencing in the last two weeks? Please mark the appropriate box for each symptom. For symptoms that do not currently apply or no longer apply, mark None. For gender-specific questions, mark N/A if they do not apply.


GENERAL SYMPTOMS (These questions apply to both genders)
Physical Exhaustion (fatigue, lack of energy, stamina, or motivation)*
Sweating (Night sweats or increased episodes of sweating)*
Sleep Problems (difficulty falling asleep, sleeping through the night, or waking up too early)*
Depressive Mood (feeling down, sad, on the verge of tears, lack of drive)*
Irritability (Mood swings, feeling aggressive, anger easily)*
Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)*
Joint and Muscular Symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)*
Difficulties with Memory*
Problems with Thinking, Concentrating, or Reasoning*
Difficulty Learning New Things*
Trouble Thinking of the Right Word to Describe Persons, Places, or Things when Speaking*
Hair Loss, Thinning, or Change in Texture of Hair*
Feeling Cold All the Time or Having Cold Hands or Feet*
Weight Gain or Difficulty Losing Weight Despite Diet and Exercise*
Dry or Wrinkly Skin*
Increase in Frequency or Intensity of Headaches or Migraines*
Sexual Problems (change in sexual desire, sexual activity, orgasm, and/or satisfaction)*
FEMALE-SPECIFIC SYMPTOMS (any other symptoms or concerns/select N/A if these do not apply to you.)
Hot Flashes*
Vaginal Symptoms (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)*
Bladder Problems (difficulty in urinating, increased need to urinate, incontinence)*
MALE-SPECIFIC SYMPTOMS (any other symptoms or concerns/select N/A if these do not apply to you.)
Erectile Changes (weaker erections, loss of morning erections)*
Ejaculations (infrequent or absent)*
Any Other Symptoms or Concerns