What is your age? *

Have you ever been on TRT in the past? *

Yes

No

Are you currently on TRT? *

Yes

No

Do you have a decrease in libido (sex drive)? *

Yes

No

Do you have a lack of energy? *

Yes

No

Have you noticed a decrease in strength and/or endurance? *

Yes

No

Do you find it difficult to concentrate or remember things?

Yes

No

Have you noticed a decrease in your motivation or drive? *

Yes

No

Are your erections less strong?

Yes

No

Has there been a recent deterioration your work performance? *

Yes

No

Have you noticed an increase in body fat especially around your midsection? *

Yes

No

Have you noticed a recent deterioration in your ability to play sports/partake in your hobbies? *

Yes

No

First Name

Last Name

Phone *

Email *

Date of birth

I agree to allow Men's Health Co. contact me in-regards to this survey, hormone replacement therapy and other health practices. By providing my phone number, I agree to receive text messages or phone calls from Men's Health Co..

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