Low Testosterone Assessment

*Your Name

*Your Email

1. How would you rate your sex drive?
Please choose...1 (Very low)2345 (Very high)

2. How would you rate your energy level?
Please choose...1 (Very low)2345 (Very high)

3. How would you rate your strength/endurance?
Please choose...1 (Very poor)2345 (Excellent)

4. How would you rate your enjoyment of life?
Please choose...1 (Not at all)2345 (A lot)

5. How would you rate your happiness level?
Please choose...1 (Very unhappy)2345 (Very happy)

6. How strong are your erections?
Please choose...1 (Extremely weak)2345 (Extremely strong)

7. How would you rate your work performance over the past 4 weeks?
Please choose...1 (Very poor)2345 (Excellent)

8. How often do you feel unusually tired or drowsy after eating a meal?
Please choose...NeverRarelySometimesOftenAlways

9. How would you rate your sports ability over the past 4 weeks?
Please choose...1 (Very poor)2345 (Excellent)

10. How much height have you lost?
Please choose...1 (None)2 (0.5 to 0.9 inch)3 (0.1 inch to 2 inch)4 (2 inches or more)5 (1.5 to 1.9 inches)6 (1 to 1.4 inches)

Self-Evaluation Hormone Survey

LTh – Thyroid

Problems with weight gainFeeling cold when others don’tConstipationLow energyDepression or low moodsDry skinDry hairBrittle, thin or splitting nailsHoarseness, difficulty swallowingExercise doesn’t feel good

LAd – Low Adrenals

Easily frazzled, irrational, easily startledDifficulty recovering from unusual stressDizziness upon standing up, fainting, low blood pressureLow stamina for stress; avoids confrontationSweating when nervousFeeling like you’re always stressed outLow tolerance to caffeine, alcohol, drugs or odorsUnusual fatigue, especially in the morning; feeling better at nightCraving for salt; poor tolerance to missed mealsTired but wired with low reserves

HAd – High Adrenals

Becoming confused or frazzled when rushedSwelling of fingers, face, ankles or limbsHeart palpitations or high blood pressureUnhealthy thinning skin, extra oily skin, bruise easilyIncrease in facial or body hairSleep problems (awake most of the night)High triglyceridesCravings for sugar; blood sugar imbalanceWeak muscles, loss of muscle, or restless legsChronic tension all day, or low-grade headaches for days on end

F. LTe – Low Testosterone (Men Only)

FatiguePoor tolerance for exercisePoor memory or concentrationLoss of libidoDepression or anxietyLoss of motivation or competitive edgeLow self-esteemGetting fat around the abdomen, ‘love handles’Loss of bone densityErectile dysfunctionAndropauseLoss of morning erectionSleep apneaHeadaches or migraines

Your Phone Number

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