BioTE Health Assessment | North Beach Plastic Surgery

Male Symptom Questionnaire

Health Assessment for Men

Symptoms

Never
(0)

Mild
(1)

Moderate
(2)

Severe
(3)

Very Severe
(4)

Sweating (night sweats or excessive sweating)

Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)

Increased need for sleep or falls asleep easily after a meal

Depressive mood (feeling down, sad, lack of drive)

Irritability (mood swings, feeling aggressive, angers easily)

Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)

Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)

Sexual problems (change in sexual desire or in sexual performance)

Bladder problems (difficulty in urinating, increased need to urinate)

Erectile changes (less strong erections, loss of morning erections)

Joint and muscular symptoms (Joint pain or swelling, muscle weakness, poor recovery after exercise)

Difficulties with memory

Problems with thinking, concentrating or reasoning

Difficulty learning new things

Trouble thinking of the right word to describe persons, places or things when speaking

Increase in frequency or intensity of headaches/migraines

Rapid hair loss or thinning

Feel cold all the time or have cold hands or feet

Weight gain, increased belly fat, or difficulty losing weight despite diet and exercise

Infrequent or absent ejaculations

Total

Severity Score	Range
Mild	1-20
Moderate	21-40
Severe	41-60
Very Severe	61-80

Severity Score

Range

Mild

1-20

Moderate

21-40

Severe

41-60

Very Severe

61-80

Female Symptom Questionnaire

Health Assessment for Women

Symptoms

Never
(0)

Mild
(1)

Moderate
(2)

Severe
(3)

Very Severe
(4)

Hot flashes

Sweating (night sweats or increased episodes of sweating)

Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)

Depressive mood (feeling down, sad, on the verge of tears, lack of drive)

Irritability (mood swings, feeling aggressive, angers easily)

Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)

Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)

Sexual problems (change in sexual desire, in sexual activity and/or orgasm and satisfaction)

Bladder problems (difficulty in urinating, increased need to urinate, incontinence)

Vaginal symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse)

Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)

Difficulties with memory

Problems with thinking, concentrating or reasoning

Difficulty learning new things

Trouble thinking of the right word to describe persons, places or things when speaking

Increase in frequency or intensity of headaches or migraines

Hair loss, thinning or change in texture of hair

Feel cold all the time or have cold hands or feet

Weight gain or difficulty losing weight despite diet and exercise

Dry or wrinkled skin

Total:

Severity Score	Range
Mild	1-20
Moderate	21-40
Severe	41-60
Very Severe	61-80

Severity Score

Range

Mild

1-20

Moderate

21-40

Severe

41-60

Very Severe

61-80

5.0

from 100+ Reviews

Mon-Fri: 8:30am – 5:00pm

North Beach Plastic Surgery is a fictitious name associated with Sailon Plastic Surgery, LLC, and is not a business entity in and of itself. The physicians of Sailon Plastic Surgery, LLC, and of Jablonka Plastic Surgery, LLC, although they share office locations, are not affiliated at this time. Instead, due to the nature of the complimentary skill sets of each practice's physicians, the practices work in a collaborative manner in accordance with applicable federal and state healthcare laws.

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BioTE Health AssesmentNorth Beach Plastic Surgery

Male Questionnaire

Female Questionnaire

Male Symptom Questionnaire

Female Symptom Questionnaire

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