Hormone Therapy Pre-Assessment for Men
Please take the following pre-assessment that can help determine your need for hormone therapy. All fields are required.
1. I am having a problem achieving an erection.
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None
Mild
Moderate
Severe
2. I feel more tired and exhausted. I do not do the things I used to like to do as often.
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None
Mild
Moderate
Severe
3. I am gaining fat or have lost muscle or strength.
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None
Mild
Moderate
Severe
4. I am losing energy and can't exercise like I used to.
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None
Mild
Moderate
Severe
5. My erections are not as strong as they used to be.
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None
Mild
Moderate
Severe
6. I am more irritable, even short tempered more often.
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None
Mild
Moderate
Severe
7. It is getting more difficult to concentrate or hear or see clearly.
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None
Mild
Moderate
Severe
8. I may fall asleep during the day or earlier than I used to at night.
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None
Mild
Moderate
Severe
9. My skin looks thinner and more wrinkled or blemished.
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None
Mild
Moderate
Severe
10. I forget numbers, names, and everyday things more often.
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None
Mild
Moderate
Severe
Full Name
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First Name
Last Name
Email Address
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Gender
*
Select the preferred time for a FREE review with a patient representative:
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9am–12pm
12pm–3pm
3pm–6pm
When we receive your results we will place $50.00 on
your account towards a first visit with us!
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