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Are you the man you used to be?
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Name
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First
Last
Date of Birth
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Phone
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Email
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1. Have you noticed a drop in your sex drive?
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Yes
No
2. Are you finding it harder to get or keep strong erections during intercourse?
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Yes
No
3. Are you feeling more tired or less energetic than usual?
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Yes
No
4. Do you feel like you're running out of steam more often?
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Yes
No
5. Have you noticed a drop in your strength, endurance or muscle mass?
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Yes
No
6. Have you put on some extra weight recently?
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Yes
No
7. Are you finding it harder to enjoy the things you once loved?
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Yes
No
8. Do you feel like you’re more irritable or short-tempered these days?
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Yes
No
9. Have you been having trouble concentrating or find yourself forgetting things more often?
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Yes
No
10. Do you find yourself nodding off after dinner?
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Yes
No
11. Is your work not going as well as it used to?
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Yes
No
12. Do you just feel old and not as motivated as you used to be?
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Yes
No
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