AMS Checklist -BEFORE HRT Place an “X” for EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE. 01. Decline in your feeling of general well-being (general state of health, subjective feeling) None Mild Moderate Severe Extremely Severe 02. Joint pain and muscular ache (lower back pain, joint pain, pain in a limb, general back ache) None Mild Moderate Severe Extremely Severe 03. Excessive sweating (unexpected/sudden episodes of sweating, hot flushes independent of strain) None Mild Moderate Severe Extremely Severe 04. Sleep problems (difficulty in falling asleep difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness) None Mild Moderate Severe Extremely Severe 05. Increased need for sleep, often feeling tired None Mild Moderate Severe Extremely Severe 06. Irritability (feeling aggressive, easily upset about little things, moody) None Mild Moderate Severe Extremely Severe 07. Nervousness (inner tension, restlessness, feeling fidgety) None Mild Moderate Severe Extremely Severe 08. Anxiety (feeling panicky) None Mild Moderate Severe Extremely Severe 09. Physical exhaustion / lacking (general decrease in performance, reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, of having to force oneself to undertake 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, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use) 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, lacking desire for sexual intercourse) None Mild Moderate Severe Extremely Severe Please share any additional comments about your symptoms you would like to address. Do you have cold hands and feet? Yes No Do you have daily bowel movements? Yes No Do you have gas, bloating or abdominal pain after eating? Yes No Please select your WEEKLY Activity Level based on this criteria Physical activity that accelerates heart rate / Breathlessness 0-1 day per week (Low) 2-3 days per week (Average) More than 3 days per week (High) Please list any prior hormone therapy? Recent PSA: Recent Digital Rectal Exam (Date): MM DD YYYY Normal / Abnormal History of Prostate problems or Biopsy. If so, please provide details. -FOR OFFICE USE ONLY- CHART ID: DOB: APPT DATE: MM DD YYYY Thank you!