Request Information - Men Name * First Name Last Name Email * Phone (###) ### #### Preferred Contact Method Phone Text Email Best Time to Contact You Morning Afternoon Evening To what extent have you experienced any of the following: Sleep problems (Difficulty falling asleep, sleeping through the night or walking up too early) Never Mild Moderate Severe Highly Severe Increased need for sleep or falls asleep easily after a meal Never Mild Moderate Severe Highly Severe Sweating (night sweats or excessive sweating) Never Mild Moderate Severe Highly Severe Depressive mood (feeling down, sad, on the verge of tears, lack of drive) Never Mild Moderate Severe Highly Severe Irritability (mood swings, feeling panicked, feeling nervous, inner tension) Never Mild Moderate Severe Highly Severe Anxiety (inner restlessness, feeling panicked, feeling nervous, inner tension) Never Mild Moderate Severe Highly Severe Physical exhaustion (general decrease in muscle strength or endurance, decresase in work performance, fatigue, lack of energy, stamina or motivation) Never Mild Moderate Severe Highly Severe Sexual problems (change in sexual desire or in sexual performance) Never Mild Moderate Severe Highly Severe Bladder problems (difficulty in urinating, increased need to urinate) Never Mild Moderate Severe Highly Severe Erectile changes (decreased erections, loss of morning erections) Never Mild Moderate Severe Highly Severe Joint and muscular sumptoms (joint pain or swelling, muscle weakness, poor recovery after exercise) Never Mild Moderate Severe Highly Severe Difficulties with memory Never Mild Moderate Severe Highly Severe Problems with thinking, concentrating or reasoning Never Mild Moderate Severe Highly Severe Difficulty learning new things Never Mild Moderate Severe Highly Severe Trouble thinking of the right word to describe persons, places or things when speaking Never Mild Moderate Severe Highly Severe Increase in frequency or intensity of headaches/migraines Never Mild Moderate Severe Highly Severe Rapid hair loss or thinning Never Mild Moderate Severe Highly Severe Feel cold all the time or have cold hands or feet Never Mild Moderate Severe Highly Severe Weight gain, increased belly fat, or difficulty losing weight despite diet and exercise Never Mild Moderate Severe Highly Severe Infrequent or absent ejaculations Never Mild Moderate Severe Highly Severe How did you hear about us? Friend Social Media Internet search BioTe Website Other If Other, please explain Referral Did anyone refer you to us? Who can we thank? Newsletter Sign up Stay informed and subscribe to our monthly newsletter to receive exclusive content, sales, promotions and notifications! Sign me up! Not at this time This form collects your name, location, phone and email so we may contact you about your request. Please read our Privacy Policy to find out how we protect and manage your data. * I grant Advanced Health and Wellness Center consent to collect my contact information. Thank you!We will be in contact with you soon. info@advancedhealthandwellnesskalamazoo.com(269) 492-65061815 Henson Avenue Kalamazoo, MI49048
