Do you have any allergies? (*) ---YesNo
If yes, please list:
Next
Are you currently taking any other than those for Hormone/Testosterone Therapy? If so, please list each medication, dosage and frequency below:
Additional Information:
Do any of the following apply:
Have you noticed a decrease in your sex drive? (*) ---YesNo
Have you noticed a decrease in energy levels? (*) ---YesNo
Do you feel weaker or have less stamina? (*) ---YesNo
Do you feel tired all of the time? (*) ---YesNo
Have you noticed decreased work performance? (*) ---YesNo
Are you more lethargic after dinner? (*) ---YesNo
Are your erections less hard? (*) ---YesNo
Are you prone to sadness or anger? (*) ---YesNo
Has your height diminished? (*) ---YesNo
Are you suffering from less vitality? (*) ---YesNo
Additional information for us to better understand anything you answered yes to:
Please check all that apply: Arthritis or autoimmune disordersBladder disordersCancer of any typeClotting disordersContagious conditionDepressionDiabetesDigestive disordersDisorder of the nervous systemEdema or SwellingExcessive snoringGenetic DisordersHead TraumaHearing disordersHeart disease or any heart related issuesHepatitis of any typeHigh blood pressureHigh CholesterolHIV or related diseaseHormonal imbalance of any typeIllnesses contracted while abroadImmune deficiency of any typeKidney disordersLife threatening conditionsLiver disordersLung disordersMuscular or bone disordersPhysical defect or deformityPoor CirculationPsychiatric disordersPsychiatric HospitalizationsSeizure disorderSkin disordersSleep ApneaStrokesTesticular or genital problemsUpper respiratory, sinus disordersVision disorders
