Low T

Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Email

Do you have a low sex drive?

Have you noticed a difficulty achieving or maintaining an erection?

Do you have a lack of energy and/or lack of endurance?

Do you have decreased strength or loss of muscle?

Have you noticed a loss of body hair and/or decreased need to shave?

Do you notice a decreased sense of ‘enjoyment in life?

Do people tell you that you are moody or grumpy?

Have you been experiencing night sweats or hot flashes?

Has there been a recent deterioration in work performance?

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