| Please check those that
apply, rating it's severity.
None Mild Mod.
Severe Extreme
- Easily fatigued, tired or loss of
energy ____
____ ____ ____
____
- Depression, low or negative
mood
____ ____ ____
____ ____
- Irritable, angry, or general bad tempered
____ ____ ____
____ ____
- Anxious or
nervous
____ ____ ____
____ ____
- Loss of memory and/or
concentration
____ ____ ____
____ ____
- Relationship problems with
partner
____ ____ ____
____ ____
- Loss of sex drive or
libido
____ ____ ____
____ ____
- Erection or potency
problems
____ ____ ____
____ ____
- Dry skin on face or
hands
____ ____ ____
____ ____
- Excessive flushing/sweating, day or night
____ ____ ____
____ ____
- Backache, joint pains or
stiffness
____ ____ ____
____ ____
- Heavy drinking, past or
present
____ ____ ____
____ ____
- Loss of
fitness
____ ____ ____
____ ____
- Feeling
over-stressed
____ ____ ____
____ ____
- Experiencing reduced muscle
mass
____ ____ ____
____ ____
- Decrease in
strength
____ ____ ____
____ ____
- Increase in central/upper body
fat
____ ____ ____
____ ____
- The age you
feel
30__ 40__ 50__ 60__
70+_
- Have you had: Adult
mumps
____
- Have you had: Testicular
trauma
____
- Have you had: Orchitis (infection of the
testicles)
____
- Have you had: Prostate operation or
inflammation
____
- Have you had: Persistent urinary
infections
____
- Have you had:
Vasectomy
____
- Are you:
Obese
____
- Have you had: Cardiovascular
Disease
____
- Have you had: Elevated lipid
levels
____
- Have you had: Sugar metabolism problems (insulin resistance or
diabetes) ____
TOTAL CHECKS IN EACH COLUMN ____
____ ____ ____ ____
Multiply checks
by: x0 x1
x2 x3 x4
TOTAL SCORES ____ + ____ +
____ + ____ +____
GRAND TOTAL ANDROPAUSE SCORE = ______
RESULTS OF ANDROPAUSE QUESTIONNAIRE:
Score Interpretation of score:
0 - 9……...…..Unlikely to have Andropause
10-19………...….Possible Andropause
20-29…….…....Probable Andropause
30-39….……....Definite Andropause
40+…….......Advanced Andropause
If you have scored 10 and above, you owe
it to yourself and everyone else around you to investigate and correct any
hormonal imbalances detected.
CALL
TO MAKE AN APPOINTMENT!
It doesn't have to be like this.
Please copy the above test and bring it to your appointment.
|
Andropause Questionnaire