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Follow-Up Form

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.

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
Calculated Results

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

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)

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

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself

(feeling that you are a failure or have let yourself or your family down)

Trouble concentrating on things

(such as reading the newspaper or watching television)

Moving or speaking so slowly that other people could have noticed or the opposite – being so fidgety or restless that you have been moving around a lot more

Thoughts that you would be better off dead, or of hurting yourself in some way

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Total score:

The implications of the scores are as follows:

  • 5-9 minimal depression symptoms

  • 10-14 mild depression symptoms

  • 15-19 moderately severe depression symptoms

  • 20-27 severe depression symptoms

General Anxiety Disorder (GAD-7)
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”.

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it’s hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Total score:

The implications of the scores are as follows:

  • 0-4 minimal anxiety

  • 5-9 mild anxiety

  • 10-14 moderate anxiety

  • 15-21 severe anxiety

Please list ALL Medications and Supplements that you use AT THIS TIME.

If not applicable, leave blank.

Medications
Dose

(mg., pill, etc.)

Times Per Day or Week

(# TPD or # TPW)

Supplements
Dose

(mg., pill, etc.)

Times Per Day or Week

(# TPD or # TPW)

Please inform of any changes in your general health and lifestyle after your previous consultation.

You have successfully submitted your Follow-Up form.

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