Men's Evaluation Form

Thank you for taking time to fill out the evaluation form. If you have any questions or have not heard from a staff member within 48 hours please do not hesitate to call us at 1-800-939-5545.

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* Required information.
Today's Date: *
Name: *
Street Address: *
City, State and Zip Code: *
Phone Number: *
Email Address: *
Age: *
Height *
Weight *
Date of Birth: *
Please select all that apply to you: * (multiple choice, hold down with 'CTRL' & left mousebutton)
Please list all perscription and non-perscription medications that you are taking: *
Do you have any drug allergies? *
Do you feel more fatigued and/or tired than usual? *
Mild
Moderate
Severe
Hve you noticed a decrease in your muscle mass? *
Mild
Moderate
Severe
Have you experienced a loss in muscle strength? *
Mild
Moderate
Severe
Have you experienced an increase in joint or muscle pains? *
Mild
Moderate
Severe
Have you noticed an increase in waist size? *
Mild
Moderate
Severe
Decrease in sex drive? *
Mild
Moderate
Severe
Difficulty establishing and/or maintaining full erections? *
Mild
Moderate
Severe
Decrease in spontaneous early morning erections? *
Mild
Moderate
Severe
Have you experienced a change in your usual sleep pattern? *
Mild
Moderate
Severe
Do you experience less enjoyment in personal interests and hobbies? *
Mild
Moderate
Severe