EmailMeForm
***********MALE SYMPTOM LIST (follow-up)**********
**************Enter symptoms in the following fields**************
NAME
First
Last
DATE
MM
/
DD
/
YYYY
PHONE
###
-
###
-
####
D.O.B.
MM
/
DD
/
YYYY
EMAIL
STATE
CV
FWB
TAMPA
COLO
OTHER STATE
CURRENT FORMULA
AND ALL OTHER
MEDICATIONS OR SUPPLEMENTS YOU
ARE CURRENTLY
TAKING
****INCLUDE NAME/STRENGTH/DOSING FREQUENCY****
Loss of
Libido
none
mild
moderate
severe
extreme
improved
Loss of
Muscle
none
mild
moderate
severe
extreme
improved
Lack of Motivation
none
mild
moderate
severe
extreme
improved
Loss of Energy
none
mild
moderate
severe
extreme
improved
Irritability
none
mild
moderate
severe
extreme
improved
Depressed
none
mild
moderate
severe
extreme
improved
Erectile
Problems
none
mild
moderate
severe
extreme
improved
Difficulty
with
Orgasm
none
mild
moderate
severe
extreme
improved
Weight
Gain
Around
Waist
none
mild
moderate
severe
extreme
improved
Sleep
Issues
none
mild
moderate
severe
extreme
improved
LAB RESULTS
UPLOAD
USE THIS FIELD TO UPLOAD A PHOTO OF YOUR LABS OR ANY RELEVANT MEDICAL DOCUMENT
ENTER YOUR DOCTOR'S
NAME
ENTER NAME OF YOUR CURRENT DOCTOR OR PRACTITIONER
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