ADAM Questionnaire Form
ADAM questionnaire about symptoms of low testosterone (Androgen Deficiency in the Aging Male) This basic questionnaire can be very useful for men to describe the kind and severity of their low testosterone symptoms. If you Answer Yes to number 1 or 7 or if you answer Yes to more than 3 questions, you may have low Testosterone.
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
1. Do you have a decrease in libido (sex drive)?
Please Select
Yes
No
2. Do you have a lack of energy?
Please Select
Yes
No
3. Do you have a decrease in strength and/or endurance?
Please Select
Yes
No
4. Have you lost height?
Please Select
Yes
No
5. Have you noticed a decreased "enjoyment of life"
Please Select
Yes
No
6. Are you sad and/or grumpy?
Please Select
Yes
No
7. Are your erections less strong?
Please Select
Yes
No
8. Have you noticed a recent deterioration in your ability to play sports?
Please Select
Yes
No
9. Are you falling asleep after dinner?
Please Select
Yes
No
10. Has there been a recent deterioration in your work performance?
Please Select
Yes
No
Signature
Submit
Should be Empty: