Male Assessment

This questionnaire is a modified version adapted from Lunenfeld B, Gooren L, eds. Textbook of Mens’ Health. London: Parthenon Publishing, 2002:34.

Which of the following symptoms apply to you at this time? Please mark the appropriate box for each symptom.

  1. Decline in your feeling of general well-being
    (general state of health, subjective feeling)

    None
    Mild
    Moderate
    Severe
    Extremely Severe
  2. Joint pain and muscular ache
    (lower back pain, joint pain, pain in a limb, general back ache)

    None
    Mild
    Moderate
    Severe
    Extremely Severe
  3. Excessive sweating
    (unexpected episodes of sweating, hot flushes)

    None
    Mild
    Moderate
    Severe
    Extremely Severe
  4. Sleep problems
    (difficulty in falling asleep or sleeping through,
    waking up early, poor sleep, sleeplessness)

    None
    Mild
    Moderate
    Severe
    Extremely Severe
  5. Increased need for sleep, often feeling tired
    None
    Mild
    Moderate
    Severe
    Extremely Severe
  6. Irritability
    (feeling aggressive, easily upset about little things, moody)

    None
    Mild
    Moderate
    Severe
    Extremely Severe
  7. Nervousness
    (inner tension, restlessness, feeling fidgety)

    None
    Mild
    Moderate
    Severe
    Extremely Severe
  8. Anxiety
    (feeling panicky)

    None
    Mild
    Moderate
    Severe
    Extremely Severe
  9. Physical exhaustion/lacking vitality
    (decrease in performance, reduced interest,
    feeling of achieving less, forcing oneself to activities)

    None
    Mild
    Moderate
    Severe
    Extremely Severe
  10. Decrease in muscular strength
    (feeling of weakness)

    None
    Mild
    Moderate
    Severe
    Extremely Severe
  11. Depressive mood
    (feeling down, sad, lack of drive, mood swings)

    None
    Mild
    Moderate
    Severe
    Extremely Severe
  12. Feeling that you have passed your peak
    None
    Mild
    Moderate
    Severe
    Extremely Severe
  13. Feeling burnt out, having hit rock-bottom
    None
    Mild
    Moderate
    Severe
    Extremely Severe
  14. Decrease in beard growth
    None
    Mild
    Moderate
    Severe
    Extremely Severe
  15. Decrease in ability/frequency to perform sexually
    None
    Mild
    Moderate
    Severe
    Extremely Severe
  16. Decrease in the number of morning erections
    None
    Mild
    Moderate
    Severe
    Extremely Severe
  17. Decrease in sexual desire/libido
    (lacking pleasure in sex or desire for sexual intercourse)

    None
    Mild
    Moderate
    Severe
    Extremely Severe



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