Pre-consultation: Andropause (Testosterone Deficiency)

First name *

Last name *

Email *

Phone *

Date of birth *

Do you have a decrease in libido (sex drive)? *

ADAM questionnaire - validated screening tool for testosterone deficiency. Score ≥3 positive (with Q1 or Q7 positive) suggests testosterone deficiency.

Yes

No

Do you have a lack of energy? *

Yes

No

Do you have a decrease in strength and/or endurance? *

Yes

No

Have you lost height? *

Yes

No

Have you noticed a decreased enjoyment of life? *

Yes

No

Are you sad and/or grumpy? *

Yes

No

Are your erections less strong? *

Yes

No

Have you noticed a recent deterioration in your ability to play sports? *

Yes

No

Are you falling asleep after dinner? *

Yes

No

Has there been a recent deterioration in your work performance? *

Yes

No

What are your most bothersome symptoms? (Select all that apply) *

Low libido

Ectile dysfunction

Fatigue

Loss of muscle mass

Weight gain (especially abdominal)

Low mood or depression

Irritability

Poor concentration or brain fog

Reduced motivation

Sleep problems

Hot flushes or night sweats

Breast tissue enlargement

Other

When did your symptoms start? *

Gradual over years

Noticeable change in last few months

Sudden onset

After a specific event or illness

How long have you had these symptoms? *

Less than 3 months

3-6 months

6-12 months

1-2 years

More than 2 years

How severe are your symptoms overall? *

Mild - noticeable but manageable

Moderate - affecting quality of life

Severe - significantly impacting daily function

Debilitating - severely affecting work/relationships

How is your erectile function? *

Normal - full and sustained erections

Slightly reduced

Moderately impaired

Severely impaired

No erections

Do you experience morning erections? *

Presence of morning erections suggests adequate vascular function.

Regular - most mornings

Occasional

Rare

None

How is your sexual desire (libido)? *

Normal

Slightly reduced

Significantly reduced

Absent

How is your ejaculation? *

Normal

Reduced volume

Delayed

Difficulty reaching orgasm

Premature

How has this affected your partner (if applicable)?

Not applicable / no partner

Not affecting relationship

Some impact

Significant impact

Major relationship stress

Have you noticed changes in muscle mass? *

No change

Some loss of muscle

Significant loss of muscle

Have you noticed changes in body composition? *

No change

Increased abdominal fat

Significant fat gain overall

Have you noticed changes in breast tissue? *

No change

Slight tenderness

Noticeable enlargement

Have you noticed changes in body or facial hair? *

No change

Slight thinning

Significant loss

Have you had any fractures from minor injuries (suggesting osteoporosis)? *

No

Yes - describe:

How would you describe your mood? *

Normal

Some low mood

Depressed

Significantly depressed

How is your irritability? *

No more than usual

Increased

Significantly worse

Affecting my relationships

How is your concentration and memory? *

Normal

Some difficulty

Significant impairment

How is your motivation? *

Normal

Reduced

Significantly reduced

Can't motivate myself at all

How is your sleep quality? *

Good

Some difficulty

Poor

Very poor - affecting daily function

Do you snore loudly? *

No

Yes

Do you feel excessively tired during the day? *

No

Yes, some days

Yes, most days

Has anyone observed you stop breathing during sleep? *

STOP-BANG screening - sleep apnoea is both a cause and consequence of low testosterone.

No

Not sure

Yes

Do you have diabetes? *

No

Yes, type 1

Yes, type 2

Do you have obesity? *

No

Yes, BMI >30

Do you have any chronic illness? *

No

Yes

Have you had cancer treatment (chemotherapy or radiotherapy)? *

No

Yes

Have you had testicular injury or surgery? *

No

Yes

Do you have HIV? *

No

Yes, on treatment

Yes, not on treatment

Have you had pituitary gland surgery or brain injury? *

No

Yes

Have you used anabolic steroids (current or past)? *

No

Yes, currently

Yes, in the past

Do you have prostate problems? *

No

Yes - benign enlargement (BPH)

Yes - elevated PSA

Yes - history of prostate cancer

Please list all current medications:

Are you taking any opioids (pain relief)? *

No

Yes

Are you taking any SSRIs or other antidepressants? *

No

Yes

Are you taking any corticosteroids (systemic)? *

No

Yes

Are you taking any antiandrogen medications (e.g. finasteride for hair loss)? *

No

Yes - finasteride

Yes - dutasteride

Yes - other

Have you ever had testosterone replacement therapy? *

No

Yes

Do you have previous testosterone blood test results? *

No

Yes

Do you want to have children (now or in the future)? *

No

Yes, soon

Yes, eventually

Unsure

What are you hoping treatment will help with? (Select all that apply) *

Improved sexual function

Increased energy

Improved mood

Gain muscle mass

Lose abdominal fat

Improved concentration

Better sleep

Increased motivation

Other

Anything else you'd like us to know before your consultation?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

ADAM Questionnaire

Do you have a decrease in libido (sex drive)? -

Do you have a lack of energy? -

Do you have a decrease in strength and/or endurance? -

Have you lost height? -

Have you noticed a decreased enjoyment of life? -

Are you sad and/or grumpy? -

Are your erections less strong? -

Have you noticed a recent deterioration in your ability to play sports? -

Are you falling asleep after dinner? -

Has there been a recent deterioration in your work performance? -

Symptom Deep Dive

What are your most bothersome symptoms? (Select all that apply) -

When did your symptoms start? -

How long have you had these symptoms? -

How severe are your symptoms overall? -

Sexual Function

How is your erectile function? -

Do you experience morning erections? -

How is your sexual desire (libido)? -

How is your ejaculation? -

How has this affected your partner (if applicable)? -

Physical Changes

Have you noticed changes in muscle mass? -

Have you noticed changes in body composition? -

Have you noticed changes in breast tissue? -

Have you noticed changes in body or facial hair? -

Have you had any fractures from minor injuries (suggesting osteoporosis)? -

Mood & Cognitive Function

How would you describe your mood? -

How is your irritability? -

How is your concentration and memory? -

How is your motivation? -

How is your sleep quality? -

Do you snore loudly? -

Do you feel excessively tired during the day? -

Has anyone observed you stop breathing during sleep? -

Medical History

Do you have diabetes? -

Do you have obesity? -

Do you have any chronic illness? -

Have you had cancer treatment (chemotherapy or radiotherapy)? -

Have you had testicular injury or surgery? -

Do you have HIV? -

Have you had pituitary gland surgery or brain injury? -

Have you used anabolic steroids (current or past)? -

Do you have prostate problems? -

Current Medications

Please list all current medications: -

Are you taking any opioids (pain relief)? -

Are you taking any SSRIs or other antidepressants? -

Are you taking any corticosteroids (systemic)? -

Are you taking any antiandrogen medications (e.g. finasteride for hair loss)? -

Previous Testosterone Treatment

Have you ever had testosterone replacement therapy? -

Do you have previous testosterone blood test results? -

Fertility

Do you want to have children (now or in the future)? -

Treatment Goals

What are you hoping treatment will help with? (Select all that apply) -

Anything else you'd like us to know before your consultation? -

Anything else for your doctor?