Hormone Replacement Therapy Scottsdale - Mens Symptom Check List

*First Name: *Last Name: Address: City: State: Age: *E-mail: *Phone: How did you hear about us? Select One Search Engine Television Radio Friend Yellow Pages Other Would you like a CONSULT? Yes No Decrease in your general well being (General state of health, subjective feeling) Select One Never Mild Moderate Severe Extremely Severe Joint pain and muscle ache (Lower back, joint and limb pain general backache) Select One Never Mild Moderate Severe Extremely Severe Excessive Sweating (Sudden episodes of sweating, hot flashes) Select One Never Mild Moderate Severe Extremely Severe Sleep Problems (Difficulty falling & staying asleep, waking up early & feeling tired, sleeplessness) Select One Never Mild Moderate Severe Extremely Severe Increased need for sleep, often feeling tired Select One Never Mild Moderate Severe Extremely Severe Nervousness (Inner tension, restlessness, feeling fidgety) Select One Never Mild Moderate Severe Extremely Severe Anxiety (Feeling Panicky) Select One Never Mild Moderate Severe Extremely Severe Exhaustion lacking vitality (Decrease in performance and activity, lacking interest & motivation) Select One Never Mild Moderate Severe Extremely Severe Decreased in muscle strength (Decrease in Performance and activity, lacking interest & Motivation) Select One Never Mild Moderate Severe Extremely Severe Depressive Mood (Felling down, sad, lack of drive, mood swings, feeling nothing is of any use) Select One Never Mild Moderate Severe Extremely Severe *Required to submit form. Feeling that you have passed your peak Select One Never Mild Moderate Severe Extremely Severe Feeling burnt out, having hit rock bottom Select One Never Mild Moderate Severe Extremely Severe Decrease in beard growth Select One Never Mild Moderate Severe Extremely Severe Decrease in ability/frequency to perform sexually Select One Never Mild Moderate Severe Extremely Severe Decrease in number of morning erections Select One Never Mild Moderate Severe Extremely Severe Decrease in sexual desire/libido (Lacking pleasure in sex, lacking desire in sex) Select One Never Mild Moderate Severe Extremely Severe Have you got any other symptoms Select One Yes No If Yes, Please Explain: Feel free to leave any additional comments: Please type the letters in the above image, then press Submit.

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For general information regarding SottoPelle Bio Identical Hormone Replacement Therapy:

Sundown Ranch

8412 E. Shea Blvd.
Suite 101
Scottsdale, AZ 85260
480.874.1515

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