Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Survey *

Irritable

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Anxiety

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Discouragement/Pessimism

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Decreasing interest in Activities/Relationships

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Decreased Initiative/Motivation/Drive

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Decreased productivity at work

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Concentration problems

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Satisfied with Physical Apperance

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Foggy Thinking

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Decrease in Strength/Stamina

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Decrease in athletic performance

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Muscle soreness/weakness

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Weight Gain

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Increased fat on hips/breast/thigh

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Caffeine/Stimulant Cravings

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Head Hair Loss

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Dry skin/Thinning Skin

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Decreased Spontaneous Morning Erections

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Lowered Libido

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Erectile Dysfunction

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Frequent Need to Urinate

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree