Men’s MyT Survey

Your Name: *

Your Email: *

City: *

State: *

ZIP: *

Phone: *

1. Do you have a decrease in Libido (sex drive)?YesNo

2. Do you have a lack of energy?YesNo

3. Have you lost height?YesNo

4. Have you noticed a decreased "enjoyment of life"?YesNo

5. Do you experience mood swings?YesNo

6. Are your erections less strong?YesNo

7. Have you noticed a recent deterioration in your ability to play sports?YesNo

8. Have you noticed a decrease in strength and/or endurance?YesNo

9. Do you tire easily?YesNo

10. Has there been a deterioration in your work performance?YesNo

11. Do you experience sleep apnea?YesNo

12. Have you experienced a loss of muscle mass?YesNo