Low-T Assessment Questionnaire

Low-T Assessment Questionnaire
Name*
Age*
Phone Number*
Email*
Please Answer The Questions Below

You will receive 1 point for each "YES" and 0 point for each "NO". At the end, you will see your Low Testosterone Screening Score. Please be honest for a correct diagnosis.

Please choose either "YES" or "NO" for the each statement below. *

	YES	NO
Do you have a decrease in libido (sex drive)?
Do you have a lack of energy?
Do you have a decrease in strength and/or endurance?
Have you lost height?
Have you noticed a decreased "enjoyment of life"?
Are you sad and/or grumpy?
Are your erections less strong?
Have you noticed a recent deterioration in your ability to play sports?
Are you falling asleep after dinner?
Has there been recent deterioration in your work performance?

Total Low Testosterone Screening Score

Thank You For Your Submission!

In order to further diagnose you for Low-T we need a bit more information. Please contact one of our specialists at (210) 405-3747

You Qualify For Testosterone Treatment!

Based on your Low Testosterone Screening Score you qualify for Testosterone Replacement Therapy Treatment. To schedule an appointment online click the "Book Online" button below.
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