ADAM Low Testosterone Screener

Name

First NameLast Name

Date of Birth

MM/DD/YYYY

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

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 or when you sit down in the evening?

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

If you answer YES to number 1or 7 or if you answer YES to 3 or more questions you may have low testosterone. Submit this form to us and we will send you back more information.

You'll be sent a link to order labs and complete paperwork. Once we have your labs and paperwork we will contact you to schedule an appointment. If you have any questions you can call us at 814-433-2632.