This questionnaire lists symptoms and other factors most commonly found in men suffering from low testosterone. Each of the questions below is weighted, and your answers produce a general score. Our wellness consultants can review this score with you.

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Name *

Phone

Email

If you would like one of our consultants to reach out to you, please be sure to include your email address.

Do you have fatigue? *

• Yes
• No

Do you have a lack of drive? *

• Yes
• No

Do you lack initiative? *

• Yes
• No

Are you less assertive? *

• Yes
• No

Do you have a decline in your sense of well being? *

• Yes
• No

Do you have depressed moods? *

• Yes
• No

Are you frequently irritable? *

• Yes
• No

Has your self-confidence declined? *

• Yes
• No

Do you find it difficult to set goals? *

• Yes
• No

Do you have a difficult time making decisions? *

• Yes
• No

Have you had a decline in your mental sharpness? *

• Yes
• No

Has your stamina or endurance lessened? *

• Yes
• No

Have you lost muscle mass, strength or tone? *

• Yes
• No

Have you gained body fat around your waist? *

• Yes
• No

Do you have elevated cholesterol? *

• Yes
• No

Has your libido decreased? *

• Yes
• No

Has your sexual ability declined? *

• Yes
• No

Is it difficult to obtain or maintain an erection? *

• Yes
• No

Do you have sleep apnea? *

• Yes
• No

If your total score is less than 6 points, it is not likely that you have low testosterone.

Scoring between 7-20 points indicates low testosterone as a possibility.

A score above 20 points would suggest that low testosterone is very likely.

Total *

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Over the years of working in functional medicine and with patients experiencing the same concerns, we have found that specific scores correlate with the levels of issues that you may face. Our wellness consultant will be reaching out to you after your submission to discuss the results with you.

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