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Male Integrative Intake Questionnaire

Section 1: Personal & Health Background

Date of Birth
Month
Day
Year

Section 2: Hormonal & Reproductive Health

Have you noticed a decrease in libido or sexual desire?
Do you experience erectile difficulties or performance issues?
Have you noticed changes in morning erections?
Do you feel fatigued or have less stamina than usual?

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Have you experienced changes in muscle mass or strength?

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Have you noticed increased abdominal fat or weight gain?

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Do you experience mood swings, irritability, or low motivation?

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Have you had testosterone or other hormone testing before?

Section 3: Mental Focus, Stress & Sleep

Do you experience brain fog or difficulty concentrating?

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Do you feel stressed or overwhelmed most days?

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Do you have trouble falling or staying asleep?
Do you wake up feeling refreshed?

Section 4: Lifestyle Habits

Section 5: Family & Medical History

Family history of heart disease?
Family history of diabetes?
Family history of cancer?

Section 6: Wellness Priorities

Consent

This confidential questionnaire helps us understand your unique hormonal, metabolic, and lifestyle profile.  Please answer the following questions as accurately as possible.  Your responses will help us tailor a personalized plan to optimize your energy, strength, focus, and longevity.

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All information is private and reviewed personally by Dr. Sandra Mckenzie.

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