Skin Quiz | MDSkin

Step 1 of 9

11%

1. Decline in your feeling of general well-being (general state of health, subjective feeling)

None

Mild

Moderate

Severe

Extremely

Severe

2. Joint pain and muscular ache (lower back pain, joint pain,pain in a limb, general back ache)

None

Mild

Moderate

Severe

Extremely

Severe

3. Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain)

None

Mild

Moderate

Severe

Extremely

Severe

4. Sleep problems (difficulty in falling asleep difficulty in sleeping through waking up early and feeling tired, poor sleep, sleeplessness)

None

Mild

Moderate

Severe

Extremely

Severe

5. Increased need for sleep, often feeling tired

None

Mild

Moderate

Severe

Extremely

Severe

6. Irritability (feeling aggressive, easily upset about little things, moody)

None

Mild

Moderate

Severe

Extremely

Severe

7. Nervousness (inner tension, restlessness, feeling fidgety)

None

Mild

Moderate

Severe

Extremely

Severe

8. Anxiety (feeling panicky)

None

Mild

Moderate

Severe

Extremely

Severe

9. Physical exhaustion / lacking vitality (general decrease in performance,reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, of having to force oneself to undertake activities)

None

Mild

Moderate

Severe

Extremely

Severe

10. Decrease in muscular strength (feeling of weakness)

None

Mild

Moderate

Severe

Extremely

Severe

11. Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use)

None

Mild

Moderate

Severe

Extremely

Severe

12. Feeling that you have passed your peak

None

Mild

Moderate

Severe

Extremely

Severe

13. Feeling burnt out, having hit rock-bottom

None

Mild

Moderate

Severe

Extremely

Severe

14. Decrease in beard growth

None

Mild

Moderate

Severe

Extremely

Severe

15. Decrease in ability/frequency to perform sexually

None

Mild

Moderate

Severe

Extremely

Severe

16. Decrease in the number of morning erections

None

Mild

Moderate

Severe

Extremely

Severe

17. Decrease in sexual desire/libido (lacking pleasure in sex, lacking desire for sexual intercourse)

None

Mild

Moderate

Severe

Extremely

Severe

Do you have cold hands and feet?

Yes

Do you have daily bowel movements?

Yes

Do you have gas, bloating or abdominal pain after eating?

Yes

Please select your WEEKLY Activity Level based on this criteria  Physical activity that accelerates heart rate / Breathlessness

0-1 day per week (Low)

2-3 days per week (Average)

More than 3 days per week (High)

Please share any additional comments about your symptoms you would like to address.

Please list any prior hormone therapy?

Recent PSA:

Recent Digital Rectal Exam (Date):

MM slash DD slash YYYY

Normal / Abnormal

MM slash DD slash YYYY

History of Prostate problems or Biopsy. If so, please provide details.

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Message

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