Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Symptoms *

Please select all that apply

Fatigue or low energy levels

Mood swings or irritability

Reduced libido (sexual drive)

Difficulty concentrating or memory problems

Decreased muscle tone or strength

Weight gain or inability to lose weight

Sleep disturbances, such as insomnia or trouble staying asleep

Joint pain or stiffness

Hair thinning or hair loss

Hot flashes or night sweats

Changes in skin tone or elasticity

Erectile dysfunction or difficulty maintaining an erection

N/A

Health Conditions *

Please select all that apply

Personal history of prostate or breast cancer

Severe untreated sleep apnea

Personal history of heart failure, stroke, or heart attack

Personal history of liver disease

Personal history of blood clots (DVT/PE)

N/A

Do you smoke or vape tobacco? *

Yes

No