Men’s Health Questionnaire – Natural Health & Wellness Center

Do you have a lack of energy?*

Do you have a decrease in your strength and/or endurance? *

Are you less active in social activities and/or sports? *

Do you feel you're performing less at work? *

Are you sleeping too much or too little? *

Do you feel sad and/or grumpy?*

Are you forgetful?*

Do you live a stressful lifestyle? *

Have you noticed a decrease in your sex drive?*

Do you frequently get up at night to urinate?*

Do you experience any discomfort when urinating?*

Are you overweight?*

Have you lost height?*

Name*

First Last

Phone*

Email*