Full Name ( enter info so we can send your results) *

Email *

2. Do you have a decrease in libido (sex drive)? *

Yes

No

1. Do you have a lack of energy? *

Yes

No

3. Are your erections less strong? *

Yes

No

4. Do you have a decrease in strength and/or endurance? *

Yes

No

5. Have you noticed a decreased "enjoyment of life" *

Yes

No

6.Are you sad and/or grumpy? *

Yes

No

7. Have you noticed a recent deterioration in your ability to play sports?

Yes

No

8.Are you falling asleep after dinner? *

Yes

No

9. Has there been a recent deterioration in your work performance? *

Yes

No

10. Have you lost height in the past year? *

Yes

No

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