Have you put on some extra weight recently? *

Yes

No

Have you noticed a drop in your strength, endurance or muscle mass? *

Yes

No

Have you noticed a drop in your sex drive? *

Yes

No

Are you finding it harder to get or keep strong erections during intercourse? *

Yes

No

Do you feel like you're running out of steam more often? *

Yes

No

Do you find yourself nodding off after dinner? *

Yes

No

Have you been having trouble concentrating or find yourself forgetting things more often? *

Yes

No

Is your work not going as well as it used to? *

Yes

No

Do you just feel old and not as motivated as you used to be? *

Yes

No

Do you feel like you’re more irritable or short-tempered these days? *

Yes

No

Are you finding it harder to enjoy the things you once loved? *

Yes

No

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First Name

Last Name

Phone *