SELF ASSESSMENT TEST Self Assessment Test First Name(Required) Last Name(Required) Phone Number(Required)Email(Required) Is your sex drive not what is used to be?(Required) Male Female Date of Birth:(Required) MM slash DD slash YYYY Height:(Required) Weight:(Required) How Did You Hear About Us?A FriendInternet SearchEmailPrint AdsI Don't Remember?Select Location(Required)Select LocationAZ - GilbertCO - Fort CollinsFL - AventuraFL - Boca RatonFL - Delray BeachFL - DoralFL - Fleming IslandFL - Fort LauderdaleFL - JupiterFL - Merritt IslandFL - Miami DadelandFL - NaplesFL - Orlando - Lake IvanhoeFL - ParklandFL - PlantationFL - WellingtonFL - WestonFL - StuartIN - Indianapolis Clay TerranceNJ - EdgewaterNJ - RidgewoodPA - NewtownPA - PhiladelphiaTX - Flower MoundTX - HoustonTX - Houston - HeightsTX - KatyTX - San AntonioTX - SpringFL - St. JohnsAZ - ScottsdaleVA - Falls ChurchNE - OmahaNJ - MorristownNJ - Spring LakeDO YOU HAVE LOW TESTOSTERONE (LOW T)?Is your sex drive not what is used to be?(Required) Yes No Are your erections weaker?(Required) Yes No Do you have a lack of energy?(Required) Yes No Have you noticed reduction in strength or cardiovascular condition?(Required) Yes No Are you experiencing more injuries or muscle and joint aches?(Required) Yes No Are you always feeling tired?(Required) Yes No Has your strength and/or endurance lessened?(Required) Yes No Are you experiencing increased belly fat?(Required) Yes No Are you sluggish in the morning?(Required) Yes No Are you more irritable, depressed or sad?(Required) Yes No Are you fatigued more easily during exercise?(Required) Yes No Has your work performance suffered?(Required) Yes No Are you getting less restful sleep?(Required) Yes No Have you noticed a decreased drive or motivation?(Required) Yes No Have you noticed slower mental function and memory loss?(Required) Yes No A specialist will contact you with your results. Δ
