Men’s Health Assessment
Quickly share your main health goals and concerns to help Fit & Fine Health understand your needs. This assessment is for informational purposes only and does not provide medical advice.
Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
State of Residence
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other
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What are your top 1–3 health or performance goals?
*
Increase energy
Improve body composition (lose fat/gain muscle)
Increase strength and muscle
Enhance sexual health or libido
Improve erectile function
Address testosterone/hormonal concerns
Manage weight
Improve sleep
Reduce stress
Optimize nutrition
Enhance exercise/training
Boost overall performance
Other
Which symptoms or concerns are you currently experiencing? (Select all that apply)
Low energy/fatigue
Difficulty losing weight
Difficulty gaining muscle
Decreased strength
Reduced libido/sexual desire
Erectile difficulties
Mood changes or irritability
Poor sleep
High stress
Concerns about testosterone/hormones
None of the above
Other
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Next
When was your most recent laboratory testing (blood work)?
Within the past 3 months
Within the past 6 months
Within the past year
More than a year ago
Never
Are you currently using any of the following treatments? (Select all that apply)
Testosterone therapy
Other hormone therapy
Weight-loss medication
Performance, recovery, or peptide therapy
None of the above
None currently, but I have in used treatment in the past
Other
Would you like a member of the Fit & Fine Health team to contact you to discuss your goals, questions, and potential next steps?
*
Yes, please contact me
Not at this time
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