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Weight (kg)  * Height (m)   * Waist (cm) Hips (cm)
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Which of the following symptoms apply to you at this time?
Please tick the appropriate box for each symptom. For symptoms that do not apply, please mark “None”.
None
1
Mild
2
Moderate 3 Severe
4
Extremely Severe
5
  1. Decline in feeling of general well-being
    (general state of health, subjective feeling)
  1. Joint pain and muscular ache
    (low back pain, joint pain, pain in limb, general back ache)
  1. Excessive sweating
    (unexpected/sudden episodes of sweating, hot flushes independent of strain)
  1. Sleep problems
    (difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)
  1. Increased need for sleep, often feeling tired
  1. Irritability
    (feeling aggressive, easily upset about little things, moody)
  1. Nervousness
    (inner tension, restlessness, feeling fidgety)
  1. Anxiety
    (feeling panicky)
  1. Physical exhaustion/lacking vitality
    (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)
  1. Decrease in muscular strength
    (feeling of weakness)
  1. Depressive mood
    (feeling down, sad, on the verge of tears, lack of drive, mood swings, feeling nothing is of any use)
  1. Feeling that you have passed your peak
  1. Feeling burnt out, having hit rock-bottom
  1. Decrease in beard growth
  1. Decrease in ability/frequency to perform sexually
  1. Decrease in the numbers of morning erections
  1. Decrease in sexual desire/libido
    (lacking pleasure in sex, lacking desire for sexual intercourse)
         
         
Have you got any other major symptoms?
 
 
 
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Suite C802 & C808, 8th Floor, Central Wing, Wisma Consplant 1,
2 Jalan SS16/4, 47500 Subang Jaya, Selangor.
Tel : 03-5638 3660/03-5569 4337 Email : ask-prime@cambert.com.my
 
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