• Testosterone Evaluation Questionnaire

    Please complete this questionnaire with your personal health information and symptoms.

  • Basic Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Symptoms

  • Reduced sex drive (libido)?*
  • Erectile dysfunction?*
  • Fatigue or low energy?*
  • Difficulty building or maintaining muscle?*
  • Noticed a decrease in strength?*
  • Difficulty losing weight?*
  • Reduced morning erections?*
  • Depressed mood, brain fog, or difficulty concentrating?*

  • Sleep & General Health

  • Have you ever been diagnosed with sleep apnea?*
  • Do you hope to father children in the future?*
  • Are you currently using CPAP treatment?
  • Do you snore loudly?
  • Has anyone told you that you stop breathing during sleep?
  • Do you frequently feel tired during the day?

  • Testosterone History

  • If yes, when did you last use testosterone?*
  • Have you ever used testosterone replacement therapy?*
  • Have you ever used anabolic steroids?*

  • Medical History

  • Ever had prostate cancer?*
  • Do you have bothersome urinary symptoms such as weak stream, urgency, or frequent urination?*
  • Ever had a heart attack?*
  • Do you have any significant heart condition that is currently being treated by a cardiologist?*
  • Have you had a heart attack, stroke, or hospitalization for a heart condition within the past 12 months?*
  • Ever had a stroke?*
  • Do you have high blood pressure?*
  • Do you have diabetes or prediabetes?*
  • Have you ever had an elevated PSA blood test?*

  • Blood Disorders

  • Have you ever been told that your red blood cell count, hemoglobin, or hematocrit was elevated?*
  • Do you currently smoke cigarettes or use nicotine products?*

  • Medications

  • Are you currently taking any opioid pain medications?*
  • Are you currently taking Suboxone or methadone?*
  • What is your biggest concern today?*

  • Final Questions

  • Would you prefer:*
  • Primary goals for testosterone therapy*
  • Date*
     - -

  • After submitting this form, you will be directed to the next step to complete your $99 Testosterone Evaluation.

  • Should be Empty: