| First Name * |
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| Last Name * |
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| Address |
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| City |
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| State |
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| Age |
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| E-mail * |
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| Phone * |
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| How did you hear about us? |
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| Would you like a CONSULT? |
Yes
No |
Decrease in your general well being
(General state of health, subjective feeling) |
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Joint pain and muscle ache
(Lower back, joint and limb pain general backache) |
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Excessive Sweating
(Sudden episodes of sweating, hot flashes) |
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Sleep Problems
(Difficulty falling & staying asleep, waking up early & feeling tired, sleeplessness) |
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| Increased need for sleep, often feeling tired |
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Nervousness
(Inner tension, restlessness, feeling fidgety) |
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Anxiety
(Feeling Panicky) |
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Exhaustion lacking vitality
(Decrease in performance and activity, lacking interest & motivation) |
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Decreased in muscle strength
(Decrease in Performance and activity, lacking interest & Motivation) |
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Depressive Mood
(Felling down, sad, lack of drive, mood swings, feeling nothing is of any use) |
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| Feeling that you have passed your peak |
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| Feeling burnt out, having hit rock bottom |
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| Decrease in beard growth |
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| Decrease in ability/frequency to perform sexually |
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| Decrease in number of morning erections |
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Decrease in sexual desire/libido
(Lacking pleasure in sex, lacking desire in sex) |
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| Have you got any other symptoms |
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| If Yes, Please Explain |
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| Feel free to leave any additional comments |
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