Male Health Questionnaire

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4840 Roswell Road, N.E. Atlanta, Georgia 30342 Building D Suite 100
Chastain Oaks

Name
First Last
Email
Phone
Birth Date
MM slash DD slash YYYY
Have you experienced any of the following symptoms recently? Please select the number that best describes your experiences with one being extremely mild and ten being extremely severe.
Decrease in libido (sex drive)?
Lack of energy?
Decrease in strength and/or endurance?
Lost height?
Decrease in "enjoyment in life"?
Sad and/or grumpy?
Erections less strong?
Noted a recent deterioration in your ability to play sports?
Falling asleep after dinner?
Recent deterioration in your work performance?
Other
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