Male Patients Form 3

FOR LESS THAN ONE MONTH FOR 1-6 MONTHS FOR MORE THAN 6 MONTHS

IT WAS A GRADUAL LOSS If IT STARTED SUDDENLY, please specify:

NO YES

NO If YES, IT HAS, please specify:

NO If YES, I HAVE, please specify:

NONE OF THE LISTED MEDICAL CONDITIONS PSORIASIS RHEUMATOID ARTHRITIS SYSTEMIC LUPUS ERYTHEMATOSIS (SLE OR LUPUS) AUTOIMMUNE DISEASE OTHER CONNECTIVE TISSUE ILLNESSES If other, please specify:

YES NO

MALE FEMALE

NO NOT ANYMORE YES - LESS THAN 6 MONTHS YES - MORE THAN 6 MONTHS YES - MORE THAN 1 YEAR If YES, please specify any side effects:

No If YES, I AM, please specify:

I CONFIRM