ADAM Questionnaire Form

Androgen Deficiency in the Aging Male (ADAM)

Testosterone Quiz
This basic questionnaire is very useful for men to describe determine the kind and severity of their low testosterone symptoms.
Are you currently a patient/client at Impireum?
Patient Name

First NameLast Name
Today's Date

MonthDayYear
Date of Visit
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
1. Do you have a decrease in libido (sex drive)?
2. Do you have a lack of energy?
3. Do you have a decrease in strength and/or endurance?
4. Have you lost height?
5. Have you noticed a decreased "enjoyment of life"
6. Are you sad and/or grumpy?
7. Are your erections less strong?
8. Have you noticed a recent deterioration in your ability to play sports?
9. Are you falling asleep after dinner?
10. Has there been a recent deterioration in your work performance?
***Important: Follow-Up on Your Assessment***

If you Answer Yes to number 1 or 7 or if you answer Yes to more than 3 questions, you may have low Testosterone. One of our clinical team member will reach out to assist. Meanwhile Please register as a new patient.
Type a question
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Androgen Deficiency in the Aging Male (ADAM)