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:

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- 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.

Q871

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

Q872

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]

Q873

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]

Q874

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

Q875

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

Q876

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

Q877

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)

Q878

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)

Q879

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

Q880

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)

Q881

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)

Q882

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)

Q883

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)

Q884

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)

Q885

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.

Q886

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)

Q887

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

Q888

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

Q889

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

Q890

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

Q891

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)

Q892

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]

Q893

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)

Q894

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

Q895

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)

Q896

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]

Q897

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

Q898

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

Q899

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

Q900

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]

Q901

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.

Q902

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

Q903

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

Q904

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

Q905

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

Q906

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

Q907

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

Q908

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)

Q909

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)

Q910

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)

Q911

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.

Q912

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)

Q913

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)

Q914

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

Q915

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

Q916

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.

Q917

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

Q918

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)

Q919

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