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Male Symptom Assessment

Note: USC does not charge a fee to evaluate this form.

Clinic Information

Name:
Email:
Address:
City:
State:
Zip Code:
Phone:
Height:
Weight:

Fatigue, tiredness or loss of energy
Decrease in physical stamina
Feelings of depression - a sense that work, marriage or recreational activities have lost significance
Decreased libido - less desire for sex
Erection or potency problems
Loss of early morning erection
Dry skin on face or hands
Increase in waist size - weight gain, especially around mid-section
Increased fat distribution in chest area or hips
Feeling burned out, loss of motivation
Increase in aches, joint and muscle pains
Frequent use of alcohol - now or in the past
Increased irritability, anger or bad temper
Decrease in muscle mass
Current Age:
How Old Do You Feel?:
What prescription and/or non-prescription drugs are you taking? (including vitamins, herbal products, or other supplements):
What medical conditions are you being treated for?:
What medical conditions have you been treated for in the past 5 years?: