Name *

First Name

Last Name

Date

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Contact Number

(###)

###

####

Have you taken any hormones in the past?

Yes

No

1. Do you feel more fatigued and/or tired than usual?

Yes

No

2. Have you noticed a decrease in your muscle mass?

Yes

No

3. Have you experienced a loss in muscle strength?

Yes

No

4. Have you experienced an increase in joint and/or muscle pains?

Yes

No

5. Have you noticed an increase in your waist size?

Yes

No

6. Do you have trouble losing weight?

Yes

No

7. Do you have a decrease in your sex drive?

Yes

No

8. Have you experienced difficulty in establishing and/or maintaining full erections?

Yes

No

9. Have you experienced changes in your usual sleep pattern?

Yes

No

10. Do you feel a decrease in your mental sharpness?

Yes

No

11. Do you experience less enjoyment in personal interests and hobbies?

Yes

No

Agreement *

By submitting this survey, you are agreeing to allow Dr. Riske to review your medical information and acknowledging that this information is being sent over email servers and is not encrypted.

Acknowledged