SWI: MALE MENOPAUSE TEST

MALE MENOPAUSE TEST

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Birth of date: Month / Day / Year

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Questionnaire

PLEASE TAKE A MOMENT TO COMPLETE THE FOLLOWING QUESTIONS


1. Fatigue, tiredness, or loss of energy Yes No


2. Depression, low or negative mood Yes No


3. Irritability, anger or bad temper Yes No


4. Anxiety or nervousness Yes No


5. Loss of memory concentration Yes No


6. Relationship problems with partner Yes No


7. Loss of sex drive or libido Yes No


8. Erection problems during sex Yes No


9. Loss of morning erections Yes No


10. Decrease intensity of orgasm Yes No


11. Backache, joint pains or stiffness Yes No


12. Heavy drinking past or present Yes No


13. Loss of fitness Yes No


14. Do you find yourself forgetting things Yes No


15. Adult mumps? Yes No


16. Orchitis or other testicular problems Yes No


17. Postate operation Yes No


18. Vasectomy Yes No