Patient Symptoms & History Step 1 of 2 50% Please enter the patient's Salesforce Lead ID, last name, first initial, and select the patient's gender to begin.Salesforce Lead ID(Required) Gender(Required) Male Female Last Name(Required) First Initial(Required) Your SymptomsNew migraine headaches(Required) NEVER MILD MODERATE SEVERE Excessive sweating(Required) NEVER MILD MODERATE SEVERE Fatigue(Required) NEVER MILD MODERATE SEVERE Joint pain/muscle ache(Required) NEVER MILD MODERATE SEVERE Anxiety(Required) NEVER MILD MODERATE SEVERE Infrequent or absent ejaculations(Required) NEVER MILD MODERATE SEVERE Weight gain/belly fat/inability to lose weight(Required) NEVER MILD MODERATE SEVERE Sleep problems(Required) NEVER MILD MODERATE SEVERE Rapid hair loss(Required) NEVER MILD MODERATE SEVERE Increased need for sleep(Required) NEVER MILD MODERATE SEVERE Declining mental ability/focus/concentration(Required) NEVER MILD MODERATE SEVERE Decline in general well being(Required) NEVER MILD MODERATE SEVERE Feeling burned out/hit rock bottom(Required) NEVER MILD MODERATE SEVERE Decreased muscle strength(Required) NEVER MILD MODERATE SEVERE No results from E.D. medications(Required) NEVER MILD MODERATE SEVERE Breast development(Required) NEVER MILD MODERATE SEVERE Depressed mood(Required) NEVER MILD MODERATE SEVERE Shrinking testicles(Required) NEVER MILD MODERATE SEVERE Feeling you have passed your peak(Required) NEVER MILD MODERATE SEVERE Decreased desire/libido(Required) NEVER MILD MODERATE SEVERE Decreased morning erections(Required) NEVER MILD MODERATE SEVERE Decreased ability to perform sexually(Required) NEVER MILD MODERATE SEVERE Decrease in beard growth(Required) NEVER MILD MODERATE SEVERE Exhaustion/lacking vitality(Required) NEVER MILD MODERATE SEVERE Your SymptomsMemory loss(Required) NEVER MILD MODERATE SEVERE Tension(Required) NEVER MILD MODERATE SEVERE Bloating(Required) NEVER MILD MODERATE SEVERE Mental confusion(Required) NEVER MILD MODERATE SEVERE Weight gain(Required) NEVER MILD MODERATE SEVERE Breast tenderness(Required) NEVER MILD MODERATE SEVERE Difficult to climax sexually(Required) NEVER MILD MODERATE SEVERE Hot flashes(Required) NEVER MILD MODERATE SEVERE Decreased sex drive/libido(Required) NEVER MILD MODERATE SEVERE Mood changes/irritability(Required) NEVER MILD MODERATE SEVERE Depressive mood(Required) NEVER MILD MODERATE SEVERE Cold all the time(Required) NEVER MILD MODERATE SEVERE Sleep problems(Required) NEVER MILD MODERATE SEVERE Dry and wrinkled skin(Required) NEVER MILD MODERATE SEVERE Fatigue(Required) NEVER MILD MODERATE SEVERE Joint pain(Required) NEVER MILD MODERATE SEVERE Vaginal dryness(Required) NEVER MILD MODERATE SEVERE Swelling all over the body(Required) NEVER MILD MODERATE SEVERE Migraine/headaches(Required) NEVER MILD MODERATE SEVERE Hair is falling off(Required) NEVER MILD MODERATE SEVERE Night sweats(Required) NEVER MILD MODERATE SEVERE Your Family HistoryOsteoporosis(Required) YES NO Breast cancer(Required) YES NO Alzheimer’s disease(Required) YES NO Heart disease(Required) YES NO Diabetes(Required) YES NO Untitled
