Do you have a decrease in libido or sex drive? *

Yes

No

Do you have a lack of energy? *

Yes

No

Do you have decreased strength or endurance? *

Yes

No

Have you lost height? *

Yes

No

Have you noticed a decrease in enjoyment in life? *

Yes

No

Are you sad and/or grumpy? *

Yes

No

Are your erections less strong? *

Yes

No

Have you noticed a recent deterioration in playing sports? *

Yes

No

Are you falling asleep after dinner? *

Yes

No

Have you noticed a recent deterioration in work performance? *

Yes

No

Name *

First Name

Last Name

Phone *

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