Your Name:

    Your Email:

    City:

    State:

    ZIP:

    Phone:

    1. Do you have a decrease in Libido (sex drive)?
    YesNo

    2. Do you have a lack of energy?
    YesNo

    3. Have you lost height?
    YesNo

    4. Have you noticed a decreased "enjoyment of life"?
    YesNo

    5. Do you experience mood swings?
    YesNo

    6. Are your erections less strong?
    YesNo

    7. Have you noticed a recent deterioration in your ability to play sports?
    YesNo

    8. Have you noticed a decrease in strength and/or endurance?
    YesNo

    9. Do you tire easily?
    YesNo

    10. Has there been a deterioration in your work performance?
    YesNo

    11. Do you experience sleep apnea?
    YesNo

    12. Have you experienced a loss of muscle mass?
    YesNo

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