Name: _________________ Date: __________ Age:____
None Slight Medium Severe Extreme
1.
Fatigue, tiredness, or loss of energy __ __ __ __ __
2.
Depression, low or negative mood __ __ __ __ __
3.
Irritability, anger, or bad temper __ __ __ __ __
4.
Anxiety or nervousness __ __ __ __ __
5.
Loss of memory or concentration __ __ __ __ __
6.
Relationship problem with partner __ __ __ __ __
7.
Loss of sex drive or libido __ __ __ __ __
8.
Erection or potency problems __ __ __ __ __
9.
Dry skin on face or hands __ __ __ __ __
10.
Excessive sweating, day or night __ __ __ __ __
11.
Backache, joint pains or stiffness __ __ __ __ __
12.
Heavy drinking, past or present __ __ __ __ __
13.
Loss of fitness __ __ __ __ __
14.
Feeling over-stressed __ __ __ __ __
30s 40s 50s 60s 70s+
15.
The age you feel __ __ __ __ __
Total Ticks: __ __ __ __ __
Multiple ticks in each column by: 0 1 2 3 4
Total Scores: ___ ___ ___ ___ ___
If there has been adult mumps, orchitis, or other testicular problems, a prostate operation or inflammation, persistent urinary infection or vasectomy, each adds four points to the total scores.
TOTAL ANDROPAUSE SCORE ______
ANDROPAUSE RATING: 0-9 UNLIKELY, 10-19 POSSIBLE, 20-29 PROBABLE, 30-
39 DEFINITE, 40+ ADVANCED

Name: ________________ Date:_________ Age:______
Symptom
Muscle soreness and Stiffness
Reading difficulty (small print)
Sleep disturbances
Thinning or loss of hair
Date:
______
Date:
______
Date:
______
Date:
______
Poor concentration/memory lapses
Fatigue and less endurance
Libido reduction
Muscle weakness
Skin thinning
Slower injury and illness recovery
Weight gain
Psychological problems
Irritability
Depression
Indecisiveness
Loss of self-confidence
Loss of purpose & direction if life
Anxiety & fear about losing sexual potency
Erectile dysfunction
Prostate enlargement
Osteoporosis
Heart Disease and atherosclerosis
Please rate each of these symptoms on a scale from 0-10 being the most extreme. This is your perception of each of these items. There is no right or wrong answer. This will be used to see if there are changes as therapy continues.
Recommendations for treating Andropause:
1.
Eat lots of fruits, vegetables, grains, and healthy meat proteins
2.
Exercise a minimum of 30 minutes three times per week
3.
Drink lots of water
4.
Eat plenty of soy foods
5.
Eat meals rich in tomatoes
6.
Take vitamins and minerals wisely and consistently
7.
Reduce saturated fat intakes
8.
Have regularly scheduled check-ups
9.
Check hormone levels (they decrease with age)
10.
Reduce stress
11.
Healthy social life with emphasis on friendship, love, and spirituality

PATIENT INSTRUCTIONS
Sexual health is an important part on an individual’s overall physical and emotional well-being. Erectile dysfunction, also known as impotence, is one type of very common medical condition affecting sexual health. Fortunately, there are many support options for erectile dysfunction. This questionnaire is designed to help you and your doctor identify if you may be experiencing erectile dysfunction. If you are, you may choose to discuss support options with your doctor.
Each question has several possible responses. Circle the response that best describes your own situation.
Please be sure you select one and only one response for each question .
OVER THE PAST 6 MONTHS:
1. How do you rate your confidence that you could get and keep an erection?
Very low Low Moderate High Very high
1 2 3 4 5
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
Very low Low Moderate High Very high
1 2 3 4 5
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
Very low Low Moderate High Very high
1 2 3 4 5
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
Very low Low Moderate High Very high
1 2 3 4 5
5. When you attempted sexual intercourse, how often was it satisfactory for you?
Very low Low Moderate High Very high
1 2 3 4 5
YOUR SCORE _________
Add the numbers corresponding to questions 1-5. If your score is 21 or less, you may want to speak with your doctor.

MI
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