Male Questionnaire
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LABORATORY TEST RESULTS

If you have any that are still relevant to your present condition, you may enter them below.

NOTE: Measurements are in 'conventional' (U.S.)  units, with Standard International (SI) units in [brackets] where different.
 

NOTE ALSO: Lab test results can also be submitted as:

- Word processor files (.doc, .rtf)
- Adobe Acrobat files (.pdf)
- Scanned images (.jpg, .gif, .png, etc.)
- Plain text.

Simply request instructions after completing the questionnaire.

LABORATORY VALUES – BLOOD AND OTHER CELLS

Please note any known results, even if all you know is that they were "normal".  Skip all questions that you are uncertain of.  Further notes can be added against any question.

Q873

Erythrocyte Sedimentation Rate (ESR) or Red Blood Cell Sedimentation Rate. Unit: mm/h
  • Don't know
  • 0 to 15 (normal)
  • 16 to 25
  • 26 to 40
  • Over 40

Q874

Hemoglobin (Hb, HGB). Unit: g/dL [g/L] or [mmol/L]
  • Don't know
  • Under 11.0 [110] [6.8]
  • 11.0-13.9 [110-139] [6.8-8.6]
  • 14-17.4 [140-174] [8.7-10.8] (normal)
  • Over 17.4 [174] [10.8]

Q875

Hematocrit (HCT). Unit: Percent [fraction]
  • Don't know
  • Under 30% [0.30]
  • 30 to 40% [0.30-0.40]
  • 41 to 51% [0.41-0.51] (normal)
  • Over 51% [0.51]

Q876

Mean Cell or Corpuscular Hemoglobin (MCH). Unit: pg/cell
  • Don't know
  • Under 26
  • 26 to 27
  • 28 to 32 (normal)
  • Over 32

Q877

Mean Corpuscular Volume (MCV). Unit: Femtoliters; fL
  • Don't know
  • Below 75
  • 75 to 81
  • 82 to 98 (normal)
  • Over 98

Q878

Platelet count (PLT). Unit: x10^3/uL or x10^9/L
  • Don't know
  • Under 100
  • 100 to 149
  • 150 to 450 (normal)
  • Over 450

Q879

Red Blood Cell count (RBC). Unit: x10^6/uL or x10^12/L. NOTE: If your results show large numbers, divide by 1000 (i.e. 3900 becomes 3.9).
  • Don't know
  • Under 3.2 (very low)
  • 3.2 to 4.2 (low)
  • 4.3 to 5.4 (normal)
  • Over 5.4 (high)

Q880

T-helper (CD4) cells (an immune cell type, unrelated to the thyroid)
  • Don't know
  • Under 150
  • 150 to 349
  • 350 to 500
  • Over 500 (normal)

Q881

Leukocytes (White Blood Cell count - WBC). Unit: x10^3/uL or x10^9/L. NOTE: If your results show large numbers, divide by 1000 (i.e. 3900 becomes 3.9).
  • Don't know
  • Under 3.5
  • 3.5 to 4.8
  • 4.9 to 10.0 (normal)
  • Over 10.0

Q882

White Blood Cells - Neutrophil Percentage [fraction]. If you only have the absolute neutrophil count (ANC), divide white blood cell count (WBC) by ANC, and multiply by 100.
  • Don't know
  • Under 40% [0.40] (low)
  • 40 to 70% [0.40-0.70] (normal)
  • 71 to 80% [0.71-0.80] (elevated)
  • Over 80% [0.80] (high)

Q883

White Blood Cells - Lymphocyte Percentage [fraction]
  • Don't know
  • Under 20% [0.20] (low)
  • 20 to 45% [0.20-0.45] (normal)
  • 46 to 55% [0.46-0.55] (elevated)
  • Over 55% [0.55] (high)

Q884

White Blood Count - Monocyte Percentage [fraction]
  • Don't know
  • Under 4% [0.04] (low)
  • 4 to 10% [0.04-0.10] (normal)
  • 11 to 15% [0.11-0.15] (elevated)
  • Over 15% [0.15] (high)

Q885

White blood Cells - Eosinophil Percentage [fraction]
  • Don't know
  • 0 to 6% [0.00-0.06] (normal)
  • 7 to 10% [0.07-0.10] (slightly elevated)
  • 11-20% [0.11-0.20] (elevated)
  • Over 20% [0.20] (high)

Q886

White Blood Cells - Basophil Percentage [fraction]
  • Don't know
  • 0 to 2% [0.00-0.02] (normal)
  • 3 to 5% [0.03-0.05] (somewhat elevated)
  • 6 to 10% [0.06-0.10] (elevated)
  • Over 10% [0.10] (high)

Q887

What is your sperm count?
  • Don't know
  • No sperm present
  • Under 30 million (very low)
  • 30 to 100 million (low)
  • Over 100 million (normal)

LABORATORY VALUES – CHEMISTRIES

Please note any known results, even if all you know is that they were "normal".  Skip all questions that you are uncertain of.

Q888

Albumin. Unit: g/dL [g/L]
  • Don't know
  • Under 3.8 [38] (very low)
  • 3.8 to 4.2 [38-42] (low)
  • 4.3 to 5.0 [43-50] (normal)
  • Over 5.0 [50] (high)

Q889

Antinuclear Antibodies (ANA). Unit: Titre
  • Don't know
  • Under 1:40 (normal)
  • 1:40 to 1:100
  • 1:101 to 1:500
  • Over 1:500

Q890

Bilirubin, total. Unit: mg/dL [umol/L]
  • Don't know
  • 0.0 to 1.3 [0-22] (normal)
  • Recently elevated
  • Chronically elevated

Q891

Bilirubin, direct. Unit: mg/dL [umol/L]
  • Don't know
  • 0.0 to 0.3 [0-5] (normal)
  • Recently elevated
  • Chronically elevated

Q892

Bilirubin, indirect. Unit: mg/dL [umol/L]
  • Don't know
  • 0.1 to 1.0 [2-17] (normal)
  • Recently elevated
  • Chronically elevated

Q893

Cholesterol, Total. What is your total cholesterol level? Unit: mg/dL [mmol/L]
  • Don't know
  • Under 150 [3.89]
  • 150 to 200 [3.89-5.19] (normal)
  • 201 to 240 [5.20-6.22] (mildly elevated)
  • Over 240 [6.22] (elevated)

Q894

Cholesterol, HDL. What is your fasting HDL cholesterol level? Unit: mg/dL [mmol/L]
  • Don't know
  • Under 21 [0.54]
  • 21 to 35 [0.54-0.92]
  • 36 to 60 [0.93-1.55] (normal)
  • Over 60 [1.55]

Q895

Cholesterol, LDL. What is your fasting LDL cholesterol level? Unit: mg/dL [mmol/L]
  • Don't know
  • Under 100 [2.59] (normal/optimal)
  • 100 to 130 [2.59-3.38] (borderline high)
  • 131 to 160 [3.39-4.14] (high)
  • Over 160 [4.14] (very high)

Q896

Homocysteine (plasma). Unit: umol/L
  • Don't know
  • Under 5
  • 5 to 9.9 (optimal)
  • 10 to 14.9 (elevated)
  • 15 or higher

Q897

Iron, serum. Unit: ug/dL [umol/L]
  • Don't know
  • Under 20 [3.6] (very low)
  • 20-59 [3.6-10.6] (low)
  • 60-175 [10.7-31.3] (normal)
  • Over 175 [31.3] (high)

Q898

Iron, TIBC (Total Iron Binding Capacity). Unit: ug/dL [umol/L]
  • Don't know
  • Under 150 [26.9]
  • 150-239 [26.9-42.8]
  • 240-450 [42.9-80.6] (normal)
  • Over 450 [80.6]

Q899

Ferritin. Unit: ng/mL [pmol/L]
  • Don't know
  • Under 10 [22]
  • 10-17 [22-39]
  • 18-270 [40-607] (normal)
  • Over 270 [607]

Q900

Liver Enzymes. Are your liver enzymes elevated?
  • Don't know
  • No (they are normal)
  • In the past only
  • Currently slightly
  • Current significantly

Q901

Occult blood. Have lab tests found blood in your stool within the past 6 months?
  • Not tested within past 6 months / don't know
  • No, stool tested negative
  • In the past only, now resolved
  • Yes, trace or small amounts
  • Yes, enough for doctor to be concerned

Q902

Triglycerides, fasting. Unit: mg/dL [mmol/L]
  • Don't know
  • Under 40 [0.45]
  • 40 to 199 [0.45-2.25] (normal)
  • 200 to 600 [2.26-6.78]
  • Over 600 [6.78]

Q903

Uric acid (plasma). Unit: mg/dL [umol/L]
  • Don't know
  • Under 3.5 [210]
  • 3.5 to 4.5 [210-270]
  • 4.6 to 7.0 [280-420] (normal)
  • Over 7.0 [420]

LABORATORY VALUES – HORMONES

Please note any known results, even if all you know is that they were "normal".  Skip all questions that you are uncertain of.

Q904

If your DHEA level has been measured, what was the result?
  • Don't know
  • Definitely low
  • Reduced
  • Normal
  • Elevated

Q905

If your estrogen levels have been measured, what was the result?
  • Don't know
  • Very low
  • Somewhat low
  • Normal
  • Elevated

Q906

What are your melatonin levels when you are not using supplemental melatonin?
  • Don't know
  • Very low
  • Low
  • Normal
  • Elevated

Q907

If your progesterone levels have been measured, what was the result?
  • Don't know
  • Very low
  • Reduced (somewhat low)
  • Normal
  • High

Q908

If your Sex Hormone Binding Globulin (SHBG) level has been measured, what was the result?
  • Don't know
  • Very low
  • Somewhat low
  • Normal
  • Elevated

Q909

What are your testosterone levels when you are not using supplemental testosterone?
  • Don't know
  • Extremely low
  • Reduced (low)
  • Normal
  • Elevated

Q910

T3 (Free). Unit: pg/mL [pmol/L]
  • Don't know
  • Under 1.4 [0.021] (very low)
  • 1.4 to 2.0 [0.021-0.031] (low)
  • 2.1 to 4.4 [0.032-0.068] (normal)
  • Over 4.4 [0.068] (elevated)

Q911

T4 (Total). Unit: ug/dL [nmol/L]
  • Don't know
  • Under 4.5 [58] (low)
  • 4.5 to 5.9 [58-76] (low - normal)
  • 6.0 to 11.5 [77-148] (normal)
  • Over 11.5 [148] (elevated)

Q912

T4 (Free). Unit: ng/dL [pmol/L]
  • Don't know
  • Under 0.4 [5] (very low)
  • 0.4 to 0.8 [5-10] (low)
  • 0.9 to 2.0 [11-26] (normal)
  • Over 2.0 [26] (elevated)

Q913

Have you had your thyroid function tested within the last year? The usual test is for TSH (Thyroid Stimulation Hormone). Unit: uIU/mL or mIU/L
  • Don't know
  • Under 1.0 (low - too much thyroid activity)
  • 1.0 to 3.4 (normal)
  • 3.5 to 6.9 (early / marginal elevation)
  • Over 7.0 (elevated - not enough thyroid activity)

LABORATORY VALUES – NUTRIENTS

Please note any known results, even if all you know is that they were "normal".  Skip all questions that you are uncertain of.

Q914

Vitamin B6 (pyridoxine). Unit: ng/mL [nmol/L]
  • Don't know
  • Confirmed deficiency in the past
  • Under 4 [16] (low)
  • 4 to 18 [16-73] (normal)
  • Over 18 [73] (elevated)

Q915

Vitamin B12 (cobalamin). Unit: pg/mL [pmol/L]
  • Don't know
  • Confirmed deficiency in the past
  • Under 200 [150] (low)
  • 200-950 [150-700] (normal)
  • Over 950 [700] (elevated)

Q916

Urine MMA. Normal levels are below 3.8ug of MMA per mg of creatinine (below 3.6umol MMA per mmol of creatinine); Elevated levels are anything above this.
  • Don't know
  • Normal
  • Elevated

Q917

Folic Acid. Unit: nmol/L
  • Don't know
  • Confirmed deficiency in the past
  • Under 10 (low)
  • 10 to 30 (normal)
  • Over 30 (elevated)

Q918

Tryptophan. If your blood or urine tryptophan levels have been measured within the past 3 months, what was the result?
  • No / over 3 months ago / don't know
  • Very low
  • Low
  • Normal
  • Elevated

LABORATORY VALUES – X-RAYS & SCANS

Note any known results, even if they were simply "normal".  Skip all questions that you are uncertain of.  Any scans not mentioned here can be listed on the final page of this questionnaire.

Q919

Chest X-ray. If you have had one within the past year, what was the result? If abnormal, please add a note detailing any heart, lung, bone or tissue abnormalities that were found.
  • I have not had one (recently) / don't know
  • Normal, and I have never had an abnormal one
  • Normal, but I have had previous abnormal one(s)
  • It was my first abnormal one
  • Abnormal, and I have had previous abnormal one(s)

OTHER DIAGNOSTIC TESTS

Q920

Have you tried the Iodine Patch Test within the past 6 months? If so, how long did it take for the iodine patch to disappear after it was painted on your arm?
  • Never tried it / over 6 months ago / don't know
  • Less than 4 hours
  • 4 to 8 hours
  • 9 to 12 hours
  • It lasts at least 12 hours (normal)

Q921

Zinc Taste Test. If you have tried this test within the past 6 months, what was your sensation?
  • Never tried it / over 6 months ago / don't know
  • Tasteless
  • Distinctly dry, metallic, fuzzy, sweet
  • Slowly becoming objectionable (normal)
  • Rapidly objectionable
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