Male Medical Assessment

This comprehensive male medical assessment is designed to identify underlying physical, hormonal, and autoimmune factors that may impact mood, alertness, fatigue, and overall mental health functioning. Many symptoms associated with anxiety, depression, ADHD, and low motivation can be influenced by medical conditions such as testosterone imbalance, sleep disruption, inflammation, thyroid dysfunction, or medication side effects. This structured, self-scoring assessment helps uncover these connections, providing valuable insight for both clinical treatment planning and medical follow-up. Results include an AI-generated clinical summary to support therapy, coordination of care, and improved outcomes.

Male Medical Factors Assessment: Mood, Alertness, Fatigue, Autoimmune & Hormonal Screening

Double Board Certified Counseling Services, Inc.

Mark Zauss, LMHC, LPC, CCMHC, NBCC, BC-TMC, ASDCS, NATC, CCTP, CCTP II, ADHD-CCSP, C-DBT, C-PD

Provider:
Double Board Certified Counseling Services, Inc.
Mark Zauss, LMHC, LPC, CCMHC, NBCC, BC-TMC, ASDCS, NATC, CCTP, CCTP II, ADHD-CCSP, C-DBT
Email completed assessment to: [email protected]

Directions: Complete all sections that apply. This assessment screens for medical factors that may affect mood, alertness, fatigue, concentration, sleep, inflammation, and treatment planning. It is not a medical diagnosis. For urgent medical symptoms, contact a physician, urgent care, emergency services, or 911 as appropriate.

How to submit: Select “Generate AI Summary,” then select “Print / Save as PDF” or “Download Completed HTML.” Email the saved file or PDF to [email protected]. The “Email Mark” button opens your email app, but you may still need to attach the saved file manually.

Client Information

Main concerns that may affect mood, energy, alertness, or functioning

Urgent Medical Red Flags

Check any current or recent concern. These may require immediate medical attention.

Chest pain, pressure, or shortness of breath Fainting, seizure, sudden confusion, or sudden weakness New severe headache or neurological change Fever with stiff neck, rash, or severe illness Rapid unexplained weight loss Blood in stool, urine, vomit, or abnormal bleeding Suicidal thoughts, self-harm thoughts, or inability to stay safe Severe medication reaction or allergic reaction

Medical History, Labs, and Medication Factors

Known diagnoses / relevant medical history Current medications, vitamins, supplements, hormones, injections, or recent medication changes Recent labs, imaging, specialist visits, abnormal results, or pending medical workup Sleep quality, snoring, apnea concerns, insomnia, nightmares, hypersomnia, shift work, or sleep schedule concerns

Medication/Substance Factors

Recent medication start, stop, missed doses, or dose change Stimulant, sedative, opioid, steroid, antihistamine, or sleep medication use Alcohol, cannabis, nicotine, or recreational substance use affecting symptoms Caffeine or energy drink use affecting sleep/anxiety Medication side effects suspected Withdrawal, rebound, or tolerance concerns

Mood and Emotional Symptoms

Depressed mood, sadness, hopelessness, or tearfulness

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Anxiety, panic, worry, inner tension, or feeling keyed up

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Irritability, anger, low frustration tolerance, or emotional reactivity

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Mood swings or rapid emotional shifts

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Low motivation, apathy, or difficulty initiating tasks

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Reduced interest, pleasure, or enjoyment

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Alertness, Cognition, and Neurological Symptoms

Brain fog, slowed thinking, or difficulty processing information

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Daytime sleepiness, drowsiness, or nodding off

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Attention, focus, distractibility, or task completion problems

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Dizziness, lightheadedness, balance issues, or faint feelings

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Confusion, disorientation, or episodes of altered awareness

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Memory problems, word-finding difficulty, or losing track of tasks

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Fatigue, Energy, Pain, and Sleep-Related Symptoms

Fatigue, exhaustion, or low physical energy

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Muscle weakness, heaviness, or reduced stamina

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Exercise intolerance, post-exertional worsening, or prolonged recovery

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Unrefreshing sleep or waking tired despite adequate sleep time

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Body aches, chronic pain, stiffness, or pain flares

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Headaches, migraines, pressure, or head/neck pain

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Autoimmune, Inflammatory, and Systemic Symptoms

Joint pain, swelling, stiffness, or morning stiffness

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Rashes, hives, skin changes, or unexplained itching

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Low-grade fevers, chills, night sweats, or flu-like episodes

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Mouth/nose ulcers, dry eyes, dry mouth, or gland swelling

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Sun sensitivity, heat intolerance, cold intolerance, or temperature sensitivity

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Swelling, fluid retention, lymph node swelling, or unexplained inflammation

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

General Medical Systems That Can Affect Mental Health

Thyroid-type symptoms: heat/cold intolerance, hair/skin change, tremor, heart racing, weight change

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Digestive symptoms: nausea, constipation, diarrhea, reflux, appetite change, bloating, food sensitivity

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Cardiac/circulatory symptoms: palpitations, blood pressure changes, chest discomfort, racing pulse

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Respiratory symptoms: asthma, shortness of breath, allergies, oxygen/sleep-breathing concerns

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Pain condition, injury, surgery recovery, migraine, arthritis, or functional limitation

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Blood sugar/appetite symptoms: shakiness, sweating, cravings, excessive thirst, frequent urination

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Male-Specific Hormonal, Urologic, and Reproductive Factors

Reduced libido, sexual interest, or sexual functioning changes

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Erectile difficulty, ejaculation changes, pelvic discomfort, or performance anxiety connected to physical symptoms

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Symptoms possibly related to testosterone/hormonal change: low drive, reduced muscle mass, low stamina, mood changes

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Urinary frequency, urgency, pain, nighttime urination, or prostate-related concerns

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Fertility concerns, testicular pain/swelling, or reproductive health concerns

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Hair loss, acne, breast tenderness/enlargement, or other endocrine-related body changes

0 Not at all 1 Mild 2 Moderate 3 Significant 4 Severe

Male-specific notes, testing, testosterone labs, prostate/urology follow-up, or reproductive concerns

Functional Impact and Follow-Up

How are these medical or physical symptoms affecting work, relationships, parenting, school, driving, decision-making, or daily responsibilities? What medical follow-up, lab work, specialist appointment, or primary-care discussion may be needed? Anything else you want your therapist to know?

Scoring and AI Summary

Total0

Mood0

Alertness0

Fatigue0

Autoimmune0

LevelLow

Scoring guide: 0–19 lower current medical-factor burden; 20–49 mild to moderate; 50–89 moderate; 90+ high. Scores are screening indicators only and are not diagnostic.

AI-Style Clinical Summary

Generate AI Summary Copy Summary Print / Save as PDF Download Completed HTML Email Mark

This form is for behavioral health screening and care coordination only. It does not replace medical evaluation, diagnosis, or treatment.

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Please save and send to [email protected]

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