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Name: ___________________________________date: _____/____/____

KU Integrative Medicine

Mental Changes:
Symptoms: Rate symptoms on a scale of 0 - 5 for absence or severity

____ Pervasive sense of fatigue, wake up tired, “Brain fog”
____ Feeling depressed or negative
____ Feeling stressed or “burned out”
____ Feeling Irritable or angry more often
____ Anxiety or increased nervousness or “panic attacks”
____ Forgetful, poor memory
____ Unable to concentrate or maintain focus
____ Decreased assertiveness
____ Loss of motivation or initiative to start new projects, hobbies
____ Becoming a “Couch potato”
____ Feeling that work, relationships, past pleasures have lost significance
____ Total Score


Sexual Function:
Symptoms: Rate symptoms on a scale of 0 - 5 for absence or severity

____ Decreased Early Morning Erections
____ Diminished Libido
____ Difficulty achieving an erection
____ Decreased fullness or turgidity
____ Decreased ability to maintain full erection after penetration
____ Diminished strength of orgasm
____ Decreased volume of ejaculate
____ Reduced of sensation of the penis
____ Premature ejaculation ____ recent ____ long term
____ Length of time in years since first changes noted
____ Response to Viagra, Levitra or Cialis
____ Use of other methods (pump, injections)

____ Total Score

Physical Changes:
Symptoms: Rate symptoms on a scale of 0 - 5 for absence or severity

____ Feeling sore all over, aches in muscles or joints
____ Frequent neck or back pains
____ Decreased strength or stamina
____ Decrease in muscle size, fullness, tone, increased “flabbiness”
____ Increased stiffness or decreased flexibility, mobility
____ Harder to recover from heavy exercise or workout
____ Diminished effects from workouts – strength, tone, muscle
____ Increased tendency fro strains, pulled muscles
____ Shortness of breath at lower levels of exertion
____ Lack of competitive drive in sports
____ Total Score

Urologic Problems
Answer yes (+) or no (-)

____ Enlarged prostate (BPH) ____ mild ____ moderate ____ severe
____ Urinary frequently. Reduced flow, dribbling or leakage
____ Nighttime urination ____ X per night
____ Non-medical treatments ____ Saw Palmetto or combination
____ Medical Treatment: ____ Proscar / Propecia ____ Avodart ____ Flomax
____ Prostatitis ____ mild ____ moderate ____ severe ____ recurrent ____
____ Increased or ____ normal range PSA (range ______________ ng/dl)
____ Treatment for BPH ____ TURP ____ TUNA ____ Laser – Year? ____
____ Prostate cancer (Year diagnosed) ____ Gleason score ____
____ Treatment(s) ____ surgery ____ radiation ____ Cryo ____ Lupron
____ Vasectomy ____ Varicocele ____ Hydrocele ____ Hernia ____ Year? ____
____ Infertility Problem
____ Total Positives


Physical Changes
Answer yes (+) or no (-)

____ Weight Gain
____ Increasing central weight – “Beer Belly”
____ Increase in breast fat
____ Lightheadedness, dizziness, ringing in ears
____ Headaches or recent onset of migraine type headaches
____ Leg cramps or swollen ankles
____ Sleep problems, sleep apnea, night sweats, or “Hot flashes”
____ Emphysema or asthma
____ Chronic inflammatory disease, colitis, rheumatoid arthritis
____ Arthritis in shoulders, hands, hips, knees, or feet
____ Varicose veins, hemorrhoids, or varicocele
____ Loss of body hair or decreased beard growth rate

____ Total Positives

Metabolic changes

Answer yes (+) or no (-)

____ Increased cholesterol, triglycerides or decreased HDL
____ Higher blood sugar or the onset of adult type 2 Diabetes
____ High Blood Pressure
____ Shortness of breath with exercise, exertion, climbing stairs
____ Racing heart, extra beats, atrial fibrillation
____ Chest pains, heart problems, or blocked arteries
____ Past heart attack, Bypass surgery or stent
____ Past stroke or TIA (mini-stroke)
____ Thyroid gland problems
____ Adrenal gland problems
____ Kidney problems, stones, cysts, infection

____ Total Positives
____ Sum Total Positive


Name_______________________________________________ Date_____________________

Source: http://gme.kumc.edu/Documents/integrativemed/Mens%20health%20form.pdf

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