Please Answer all the following questions:
 

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Date Of Birth


1. Are you a Male who is 45 years old or older?

2. Have you ever been diagnosed with low Testosterone level ?

3. Do you have any of the following symptoms? (Please check all that apply to you)
Decreased sexual desire or libidoDecreased spontaneous erection (e.g., morning erections)Decreased energy or fatigue/feeling tiredLow mood or depressed moodLoss of body (axillary and pubic) hair or reduced shavingHot flashes

4. Have you ever been diagnosed with any of the following? (please check all that apply to you and then type the date -roughly-)
Heart Attack (Myocardial Infarction)Coronary revascularization (Coronary artery bypass graft or a stent)Ischemic strokeExternal Carotid artery stenosis > 50%Documented Lower extremity arterial disease or resting limb ischemia

If yes, please provide diagnosis date:

5. Have you ever been diagnosed with any of the following? (Please choose all that apply to you and then indicate the date and if you are taking any medications)
High blood pressureHigh cholesterol or lipidsStage 3 Chronic Kidney DiseaseDiabetes

List any medications you are currently taking:

6. Do you Smoke?

7. Have you ever used any Testosterone medications (Injections, gel .. etc) or replacements?

If Yes, when was the last dose:

8. Have you ever been diagnosed with prostate or breast Cancer?

9. Have you ever been diagnosed with enlarged prostate? If yes, please specify the abnormality:

If Yes, Describe Abnormality:

10. Do you have difficulty urinating or initiating urination?

11. Have you ever been diagnosed with Sleep apnea? If yes is it treated and controlled?

If Yes, describe treatment:

12. Have you ever been diagnosed with heart Failure? If yes, please specify the grade:

If Yes, specify grade:

13. Have you ever been diagnosed with Deep venous thrombosis or pulmonary embolism? (Blood clots in your legs, thighs or lungs)

14. Have you ever been diagnosed with chronic obstructive pulmonary disease (COPD)?

15. Have you been diagnosed with or treated for any kind of cancers over the past 2 years?

 

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After reviewing your answers, the study team will contact you to schedule a screening visit if you qualify. Thank you in advance for helping us advance science.