Low-T Clinical Evaluation Eligibility Test - Superior Genetix Health and Wellness

Begin - Step 1 of 4

Please provide your email address: *

Confirm Email

*This will be the email used for correspondence related to your results.

Age: *

Height: *

Feet & Inches

Weight" *

Lbs.

Sex *

Do you have any recent lab work that you want us to review?

Drag & Drop Files, Choose Files to Upload

Upload a PDF Lab Report if you have one.

Let's Begin With Your Symptom Assessment

Please indicate the severity of any symptoms you have experienced over the last 3–6 months.

1. Vitality & Physical Performance *

	None	Mild	Moderate
General fatigue or lack of energy	NoneGeneral fatigue or lack of energy None	MildGeneral fatigue or lack of energy Mild	ModerateGeneral fatigue or lack of energy Moderate
Decreased physical strength or endurance	NoneDecreased physical strength or endurance None	MildDecreased physical strength or endurance Mild	ModerateDecreased physical strength or endurance Moderate
Difficulty recovering after exercise/labor	NoneDifficulty recovering after exercise/labor None	MildDifficulty recovering after exercise/labor Mild	ModerateDifficulty recovering after exercise/labor Moderate
Unexplained joint pain or muscle aches	NoneUnexplained joint pain or muscle aches None	MildUnexplained joint pain or muscle aches Mild	ModerateUnexplained joint pain or muscle aches Moderate
Falling asleep shortly after dinner/lunch	NoneFalling asleep shortly after dinner/lunch None	MildFalling asleep shortly after dinner/lunch Mild	ModerateFalling asleep shortly after dinner/lunch Moderate
Night sweats or sudden hot flashes	NoneNight sweats or sudden hot flashes None	MildNight sweats or sudden hot flashes Mild	ModerateNight sweats or sudden hot flashes Moderate

2. Body Composition & Physical Changes *

	None	Mild	Moderate
Increased body fat (especially around the waist)	NoneIncreased body fat (especially around the waist) None	MildIncreased body fat (especially around the waist) Mild	ModerateIncreased body fat (especially around the waist) Moderate
Loss of muscle mass/definition	NoneLoss of muscle mass/definition None	MildLoss of muscle mass/definition Mild	ModerateLoss of muscle mass/definition Moderate
Development of breast tissue (Gynecomastia)	NoneDevelopment of breast tissue (Gynecomastia) None	MildDevelopment of breast tissue (Gynecomastia) Mild	ModerateDevelopment of breast tissue (Gynecomastia) Moderate
Loss of body hair (chest, arms, legs, or face)	NoneLoss of body hair (chest, arms, legs, or face) None	MildLoss of body hair (chest, arms, legs, or face) Mild	ModerateLoss of body hair (chest, arms, legs, or face) Moderate

3. Sexual & Reproductive Health *

	None	Mild	Moderate
Decrease in libido (sex drive)	NoneDecrease in libido (sex drive) None	MildDecrease in libido (sex drive) Mild	ModerateDecrease in libido (sex drive) Moderate
Difficulty achieving or maintaining erections	NoneDifficulty achieving or maintaining erections None	MildDifficulty achieving or maintaining erections Mild	ModerateDifficulty achieving or maintaining erections Moderate
Reduced frequency of morning erections	NoneReduced frequency of morning erections None	MildReduced frequency of morning erections Mild	ModerateReduced frequency of morning erections Moderate
Noticed decrease in semen volume	NoneNoticed decrease in semen volume None	MildNoticed decrease in semen volume Mild	ModerateNoticed decrease in semen volume Moderate
Shrunken or softer testicles	NoneShrunken or softer testicles None	MildShrunken or softer testicles Mild	ModerateShrunken or softer testicles Moderate

4. Cognitive & Emotional Well-being *

	None	Mild	Moderate
"Brain fog" or difficulty concentrating	None"Brain fog" or difficulty concentrating None	Mild"Brain fog" or difficulty concentrating Mild	Moderate"Brain fog" or difficulty concentrating Moderate
Decrease in motivation or "drive"	NoneDecrease in motivation or "drive" None	MildDecrease in motivation or "drive" Mild	ModerateDecrease in motivation or "drive" Moderate
Feeling depressed, irritable, or "grumpy"	NoneFeeling depressed, irritable, or "grumpy" None	MildFeeling depressed, irritable, or "grumpy" Mild	ModerateFeeling depressed, irritable, or "grumpy" Moderate
Recent decline in work performance	NoneRecent decline in work performance None	MildRecent decline in work performance Mild	ModerateRecent decline in work performance Moderate
Memory issues or general forgetfulness	NoneMemory issues or general forgetfulness None	MildMemory issues or general forgetfulness Mild	ModerateMemory issues or general forgetfulness Moderate

Please provide us specific details on any other symptoms you are experiencing. *

(Enter "none" if not applicable)

Please provide us a few details about your health history to ensure your treatment plan is both safe and effective.

Medical Conditions *

	Yes	No
Hypertension	YesHypertension Yes	NoHypertension No
Heart Disease	YesHeart Disease Yes	NoHeart Disease No
Stroke	YesStroke Yes	NoStroke No
Autoimmune	YesAutoimmune Yes	NoAutoimmune No
Diabetes	YesDiabetes Yes	NoDiabetes No
High Cholesterol	YesHigh Cholesterol Yes	NoHigh Cholesterol No
Obesity	YesObesity Yes	NoObesity No
Cancer	YesCancer Yes	NoCancer No
COPD/Asthma	YesCOPD/Asthma Yes	NoCOPD/Asthma No
Prostate/BPH	YesProstate/BPH Yes	NoProstate/BPH No
Gastrointestinal	YesGastrointestinal Yes	NoGastrointestinal No
Hormone disorder	YesHormone disorder Yes	NoHormone disorder No
Allergic reaction	YesAllergic reaction Yes	NoAllergic reaction No
Do you regularly use tobacco?	YesDo you regularly use tobacco? Yes	NoDo you regularly use tobacco? No
Do you regularly consume alcohol?	YesDo you regularly consume alcohol? Yes	NoDo you regularly consume alcohol? No
Do you regularly use recreational drugs?	YesDo you regularly use recreational drugs? Yes	NoDo you regularly use recreational drugs? No

Please identify and provide specifics on any other health conditions. *

(Enter "none" if not applicable)

Are you currently using any medications? Please list current medications and doses.. *

(Enter "none" if not applicable)

Have you ever used testosterone before? If yes please provide details including doses, results, length of time used etc. *

(Enter "no" if not applicable)

You evaluation will be reviewed TODAY.

Once you SUBMIT your results, they will be received our clinical staff for review.

There is no obligation to order lab work.