Follow-Up Form

First name

Last name

Email

ID number

NOTE!
You will be asked to provide detailed information about your body parameters, andropause, depression and anxiety symptoms, medications and supplements that you use. Filling out the form can take up to 10 minutes.

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WHR	Health risk
0.95 or lower	Low
0.96 - 1.0	Moderate
1.0 or higher	High
WCR (optimal )	0.7 - 0.8

BMI
Under 18.5	Underweight
18.5 - 24.9	Normal
25 - 29.9	Overweight
30 and over	Obese

WHR

WCR

BMI

Calculated Results

Chest Circumference (cm)

Waist Circumference (cm)

Hip Circumference (cm)

Blood Pressure (mm/Hg)

Pulse (bpm)

Weight (kg)

Height (cm)

NOTE!

Blood pressure and pulse must be measured at rest.
Chest circumference should be measured at the level of the nipples.
Waist circumference should be measured at the level of the navel.
If you have had a DEXA/DXA scan within the last 6 months, please indicate your total body fat.

Body parameters

Total Body Fat (%)

Aging Male Symptoms Score (AMS)

Which of the following symptoms apply to you AT THIS TIME?

For symptoms that do not apply, please mark “None”.

Decline in your feeling of general wellbeing

(general state of health, subjective feeling)

Joint pain and muscular ache

(lower limb, general back ache)

Excessive sweating

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

Sleep problems

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

Increased need for sleep, often feeling tired

Irritability

(feeling aggressive, easily upset about little things, low stress tolerance, moody)

Nervousness

(inner tension, restlessness)

Anxiety

(feeling panicky)

Physical exhaustion/lacking vitality

(general decrease in performance, reduced activity, feeling of getting less done, of having to force oneself to undertake activities)

Decrease in muscular strength

(feeling weak)

Depressive mood

(feeling down, sad, on the verge of tears, mood swings)

Feeling that you have passed your peak

Feeling burnt out, having hit rock-bottom

Decrease in beard growth

Decrease in the number of morning erections

Decrease in ability/frequency to perform sexualy

Decrease in sexual desire/libido

(lacking pleasure in sex, lacking desire for intercourse)

Do you have any other major symptoms?

Total score:

The implications of the scores are as follows:

17-26 no significant symptoms consistent with a low testosterone level
27-36 mild symptoms consistent with a low testosterone level
37-49 moderate symptoms consistent with a low testosterone level
50-85 severe symptoms consistent with a low testosterone level

Patient Health Questionnaire (PHQ-9)

Over the LAST 2 WEEKS, how often have you been bothered by any of
the following problems?

For problems that do not apply, please mark “Not at all”.

Little interest or pleasure in doing things