ADAM Questionnaire

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

1. Do you have a decrease in libido (sex drive)?* This field is required.

Yes

No

4

2. Do you have a lack of energy?* This field is required.

Yes

No

5

3. Do you have a decrease in strength and/or endurance?* This field is required.

Yes

No

6

4. Have you lost height?* This field is required.

Yes

No

7

5. Have you noticed a decreased "enjoyment of life"?* This field is required.

Yes

No

8

6. Are you sad and/or grumpy more often?* This field is required.

Yes

No

9

7. Are your erections less strong?* This field is required.

Yes

No

10

8. Have you noticed a recent deterioration in your ability to play sports?* This field is required.

Yes

No

11

9. Do you fall asleep after dinner?* This field is required.

Yes

No

12

10. Has your work performance deteriorated recently?

Yes

No