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Your Name:

Your Email:

City:

State:

ZIP:

Phone:

1. Do you have a decrease in Libido (sex drive)?
 Yes No

2. Do you have a lack of energy?
 Yes No

3. Have you lost height?
 Yes No

4. Have you noticed a decreased "enjoyment of life"?
 Yes No

5. Do you experience mood swings?
 Yes No

6. Are your erections less strong?
 Yes No

7. Have you noticed a recent deterioration in your ability to play sports?
 Yes No

8. Have you noticed a decrease in strength and/or endurance?
 Yes No

9. Do you tire easily?
 Yes No

10. Has there been a deterioration in your work performance?
 Yes No

11. Do you experience sleep apnea?
 Yes No

12. Have you experienced a loss of muscle mass?
 Yes No

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