Please fill Form Below, We Understand Each Symptom You May Be Experiencing Name *Email Address *Date *Phone *Please mark the appropriate box for each symptom you may be experiencing.Physical Exhaustion (fatigue, lack of energy, stamina or motivation)NoneMildModerateSevereVery SevereSleep Problems (difficulty falling asleep or sleeping through the night)NoneMildModerateSevereVery SevereIrritability (mood swings, feeling aggressive, angers easily)NoneMildModerateSevereVery SevereAnxiety (feeling overwhelmed, feeling panicky, or feeling nervous)NoneMildModerateSevereVery SevereDecline in drive or interest (loss of “zest for life,” feeling down or sad)NoneMildModerateSevereVery SevereJoint and muscular symptoms (poor recovery after workout, inability to add muscle, joint pain, muscle weakness)NoneMildModerateSevereVery SevereDifficulties with memory (concentration, finding the right word, or retaining information)NoneMildModerateSevereVery SevereSexual Desire or Performance (reduced or diminished)NoneMildModerateSevereVery SevereErectile changes (weaker erections, loss of morning erections)NoneMildModerateSevereVery SevereEjaculations (infrequent or absent)NoneMildModerateSevereVery SevereSweating (night sweats or increased episodes of sweating)NoneMildModerateSevereVery SevereHair loss, rapid or thinningNoneMildModerateSevereVery SevereFeeling cold all the time, having cold hands or feetNoneMildModerateSevereVery SevereHeadaches or migraines (increase in frequency or intensity)NoneMildModerateSevereVery SevereWeight (difficulty losing weight despite diet/exercise)NoneMildModerateSevereVery SevereBladder problems (difficulty in urinating, increased need to urinate)NoneMildModerateSevereVery SevereOther symptoms or unique health circumstances to take into consideration:Submit Form
