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?*

YesNo
Patient Name*

First NameLast Name
Today's Date*

MonthDayYear
Date of Visit
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
1. Do you have a decrease in libido (sex drive)?*

YESNO
2. Do you have a lack of energy?*

YESNO
3. Do you have a decrease in strength and/or endurance?*

YESNO
4. Have you lost height?*

YESNO
5. Have you noticed a decreased "enjoyment of life"*

YESNO
6. Are you sad and/or grumpy?*

YESNO
7. Are your erections less strong?*

YESNO
8. Have you noticed a recent deterioration in your ability to play sports?*

YESNO
9. Are you falling asleep after dinner?*

YESNO
10. Has there been a recent deterioration in your work performance?*

YESNO
***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.
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Androgen Deficiency in the Aging Male (ADAM)