• Low Testosterone Questionnaire

  • This basic questionnaire can be very useful for men to describe the kind and severity of their low testosterone symptoms.

  • Date*
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  • Birthday*
     - -
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  • 1. Do you have a decrease in libido (sex drive)?*
  • 2. Do you have a lack of energy?*
  • 3. Do you have a decrease in strength and/or endurance?*
  • 4. Have you lost height?*
  • 5. Have you noticed a decreased “enjoyment of life?”*
  • 6. Are you sad and/or grumpy?*
  • 7. Are your erections less strong?*
  • 8. Have you noticed a recent deterioration in your ability to play sports?*
  • 9. Are you falling asleep after dinner?*
  • 10. Has there been a recent deterioration in your work performance?*

  • If you answer “Yes” to number 1 or 7 or if you answer “Yes” to more than 3 questions, you may have low testosterone. Please print and bring your assessment to your appointment.

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  • Should be Empty: