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Testosterone & Vitality Assessment
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About Us
Personal Information
Name
(Required)
First
Last
What is your age?
(Required)
Phone
(Required)
Email
(Required)
Preferred Contact Method
(Required)
Phone
Email
Text
Medical History
Do you currently have or have a history of any of the following? (Check all that apply)
Heart disease
Diabetes
High blood pressure
Sleep apnea
Thyroid disorders
Depression or anxiety
Prostate issues (e.g., BPH or prostate cancer)
Other
Select All
Other
(Required)
Are you currently taking any medications or supplements?
Yes
No
If yes, please list:
(Required)
Have you ever had your testosterone levels tested?
Yes
No
Have you previously used testosterone therapy or hormone optimization?
Yes
No
If yes, what type and when?
(Required)
Lifestyle & Habits
How would you describe your energy levels?
Excellent
Good
Fair
Poor
How many hours of sleep do you get per night?
Less than 5
5–6
7–8
More than 8
Do you experience fatigue, especially in the afternoon?
Yes
No
Vitality & Sexual Health
Have you noticed a decrease in any of the following? (Check all that apply)
Libido (sex drive)
Morning erections
Sexual performance
Confidence
Mental clarity/focus
Muscle strength or mass
Motivation/drive
Mood stability
Select All
Do you experience:
Difficulty maintaining erections?
Yes
No
Premature ejaculation?
Yes
No
Low interest in sexual activity?
Yes
No
Goals & Expectations
What are your primary goals in seeking hormone optimization or vitality support? (Check all that apply)
Improve energy
Boost libido
Increase muscle mass
Reduce fat
Improve focus or mood
Sleep better
Overall well-being
Other
Select All
Other
(Required)
Availability for Scheduling Meetings
What Day(s) is good to meet?
(Required)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What time between 11:00 AM and 4:00 PM EST time is good for you?
(Required)
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
Phone
This field is for validation purposes and should be left unchanged.
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+1 840 841 25 69
info@email.com
