Please answer “Yes” or “No” to the following:

1. Do you have a decrease in libido (sex drive)?
▢ Yes  ▢ No

2. Do you have a lack of energy?
▢ Yes  ▢ No

3. Do you have a decrease in strength and/or endurance?
▢ Yes  ▢ No

4. Have you lost height?
▢ Yes  ▢ No

5. Have you noticed a decreased “enjoyment of life”?
▢ Yes  ▢ No

6. Are you sad and/or grumpy?
▢ Yes  ▢ No

7. Are your erections less strong?
▢ Yes  ▢ No

8. Have you noticed a recent deterioration in your ability to play sports?
▢ Yes  ▢ No

9. Are you falling asleep after dinner?
▢ Yes  ▢ No

10. Has there been a recent deterioration in your work performance?
▢ Yes  ▢ No

Scoring: A “Yes” to question 1 or 7, or to any 3 or more questions, may indicate low testosterone. This is not a diagnosis. Please schedule a consultation for lab testing and personalized evaluation.