Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Mobile Phone *

(###)

###

####

How may we contact you? *

Cell Phone

Text

E-Mail

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

Primary Care Physician

First Name

Last Name

Primary Care Physician Phone

(###)

###

####

Family History *

Have any of your parents, grandparents, or siblings experienced any of the following?

None

Heart Disease

Diabetes

Cancer

Severe Depression

Alzheimer's or Dementia

Other

Personal Medical History *

High blood pressure

Heart bypass

High cholesterol

Heart Disease (other)

Heart attack

Angina or other chest pain

Stroke or TIA

Blood clot and/or a pulmonary emboli

Arrhythmia

Pacemaker

Defibrillator

Anemia

Asthma

Emphysema

COPD

Hepatitis

HIV/AIDS

Lupus or other auto immune disease

Fibromyalgia

Trouble passing urine or take Flomax or Avodart

Chronic liver disease (fatty liver or cirrhosis)

Diabetes (Type 1)

Diabetes (Type 2)

Thyroid disease

Arthritis

Depression

Anxiety

ADD/ADHD

Cancer

Other

NONE

Are you currently on Testosterone Replacement Therapy? *

Yes

No

Hormone Assessment *

Do you experience any of the following? (Check all that apply)

Decline in your feeling of general well-being

Joint pain

Muscular aches

Excessive sweating

Sleep problems

Increased need for sleep

Fatigue

Irritability

Nervousness

Anxiety

Physical exhaustion

Lacking vitality

Mental exhaustion

Brain Fog

Decrease in muscular strength

Depressive mood

Feeling that you have passed your peak/burnt out

Decrease in ability/frequency to perform sexually

Decrease in the number of morning erections

Decrease in sexual desire/libido

Constipation

Dry skin or hair

Decrease in beard growth

Hair loss

Weight gain or inability to lose weight

I am not experiencing any symptoms at this time

ADAM Questionnaire *

Select all that apply

Decrease in libido (sex drive)

Lack of energy

Decrease in strength and/or endurance

Lost height

Decreased "enjoyment in life"

Sad and/or grumpy

Erections are less strong

Recent deterioration in ability to play sports

Falling asleep after dinner

Recent deterioration in work performance

None apply

How long have you been experiencing these symptoms? *

Less than a month

Between 1 and 6 months

Longer than 6 months

Overall how would you rate your symptoms? *

Mild

Moderate

Severe

Snoring ? *

Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?

Yes

No

Tired ? *

Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?

Yes

No

Observed ? *

Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?

Yes

No

Pressure ? *

Do you have or are being treated for High Blood Pressure?

Yes

No

Age older than 50 ? *

Are you 50 years or older?

Yes

No

Neck size large ? *

Is your shirt collar 16 inches / 40cm or larger? (Measured around the Adams apple)

Yes

No

Gender = Male ? *

Are you a male?

Yes

Are you currently experiencing pain? *

Yes

No