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Men's Health Survey
This questionnaire is about symptoms of low testosterone (Androgen Deficiency in the Aging Male).
This basic questionnaire can be very useful for men to describe the kind and severity of their low testosterone symptoms.
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* Indicates required question
Name
*
Your answer
Do you have a decrease in libido (sex drive)?
*
No
Yes
Other:
Do you have a lack of energy?
*
No
Yes
Do you have a decrease in strength and/or endurance?
*
No
Yes
Have you lost height?
*
No
Yes
Have you noticed a decreased "enjoymentof life"?
*
No
Yes
Are you sad and/or grumpy?
*
No
Yes
Are your erections less strong?
*
No
Yes
Have you noticed a recent deterioration in your ability to Yes No play sports?
*
No
Yes
Are you falling asleep after dinner?
*
No
Yes
as there been a recent deterioration in your work Yes No performance?
*
No
Yes
If you Answer Yes to number 1 or 7 or if you answer Yes to more than 3 questions, you may have low Testosterone.
Your answer
Have you had a PSA done?
*
No
Yes
If you have had a PSA what was the result?
*
0-2
2-4
4-10
>10
Other:
Please check any symptoms you may be having:
*
Difficulty Maintaining an Erection
Difficulty Obtaining an Erection
Have to get up more than once to urinate while sleeping.
Impotence
Prostate Enlargement
Prostate infection
Urgency/Hesitancy/Change in Urinary Stream
Urinary dribliing
No issues
Other:
Required
Thank you!
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