Male Hormone FormPlease set aside 5-10 minutes to fill out the form below.Note: this page DOES NOT autosave, please submit the form before exiting the tab. Name * First Name Last Name Email * Rate the following symptoms depending on the severity experienced. Please select none or leave blank if a symptom does not apply. Thyroid Deficiency 1. Fatigue None Slightly Moderate Severe Extreme Depression None Slightly Moderate Severe Extreme Weight gain None Slightly Moderate Severe Extreme Cold intolerance None Slightly Moderate Severe Extreme Dry skin None Slightly Moderate Severe Extreme Anxiety None Slightly Moderate Severe Extreme Insomnia None Slightly Moderate Severe Extreme Memory lapses None Slightly Moderate Severe Extreme Difficulty concentrating None Slightly Moderate Severe Extreme Muscle aches/stiffness None Slightly Moderate Severe Extreme Constipation None Slightly Moderate Severe Extreme Rashes None Slightly Moderate Severe Extreme Adrenal Imbalance 2. Fatigue None Slightly Moderate Severe Extreme Allergies None Slightly Moderate Severe Extreme Muscle aches None Slightly Moderate Severe Extreme Decreased sex drive None Slightly Moderate Severe Extreme Increased infections None Slightly Moderate Severe Extreme Decreased muscle mass None Slightly Moderate Severe Extreme Feeling cold None Slightly Moderate Severe Extreme Neck stiffness None Slightly Moderate Severe Extreme "Burned out" feeling None Slightly Moderate Severe Extreme Morning sluggishness None Slightly Moderate Severe Extreme Feeling unable to cope None Slightly Moderate Severe Extreme Irritable None Slightly Moderate Severe Extreme Tired but feeling wired None Slightly Moderate Severe Extreme Weight gain (waist) None Slightly Moderate Severe Extreme Impaired memory None Slightly Moderate Severe Extreme Loss of scalp hair None Slightly Moderate Severe Extreme Depression None Slightly Moderate Severe Extreme Low blood pressure None Slightly Moderate Severe Extreme Testosterone 3. Reduced libido None Slightly Moderate Severe Extreme Erectile dysfunction None Slightly Moderate Severe Extreme Loss of body hair None Slightly Moderate Severe Extreme Increase in body fat None Slightly Moderate Severe Extreme Loss of lean muscle mass None Slightly Moderate Severe Extreme Loss of bone density None Slightly Moderate Severe Extreme Depression None Slightly Moderate Severe Extreme Elevated insulin levels None Slightly Moderate Severe Extreme Elevated cholesterol profile None Slightly Moderate Severe Extreme High blood pressure None Slightly Moderate Severe Extreme Thank you for your form submission. BACK TO ALL FORMS