ADAM Questionnaire

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Men’s Testosterone & Vitality Screening (ADAM Questionnaire)

(Androgen Deficiency in Aging Males)

2-minute screening to see if low testosterone may be a factor—then get a clinician-guided next-step plan.

Low energy, low drive, stubborn weight, or brain fog?

This confidential screening helps identify whether testosterone-related patterns may be contributing. If you screen positive, we’ll outline the next best step (labs + a clinician review when appropriate).

What happens next (3 steps):

Complete this 2-minute screening
Receive your screening result + recommended next step
Book your Men’s Hormone Optimization Consultation

Privacy line: Your information is encrypted and confidential.

Required checkbox (consent):

I understand this is a screening tool and not a diagnosis. I consent to be contacted about my results.

Section 1: Contact + Eligibility

First & Last Name

Age

Today's Date

State of residence

(Required; determines telehealth eligibility)

Mobile Phone

(required for scheduling follow-through)

Preferred contact Best way & Time to contact you

Text

Call

Morning

Afternoon

Evening

Section 2: ADAM Screening (2 minutes)

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

Yes No

If Yes,

Mild Moderate Severe

2. Do you have a lack of energy?

Yes No

If Yes,

Mild Moderate Severe

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

Yes No

If Yes,

Mild Moderate Severe

4. Have you lost height?

Yes No

If Yes,

Mild Moderate Severe

5. Have you noticed a decreased "enjoyment of life"?

Yes No

If Yes,

Mild Moderate Severe

6. Are you sad and/or grumpy?

Yes No

If Yes,

Mild Moderate Severe

7. Are your erections less strong?

Yes No

If Yes,

Mild Moderate Severe

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

Yes No

If Yes,

Mild Moderate Severe

9. Are you falling asleep after dinner?

Yes No

If Yes,

Mild Moderate Severe

10. Has there been a recent deterioration in your work performance?

Yes No

If Yes,

Mild Moderate Severe

Section 3: Goals

What result are you looking for most? (choose up to 2)

More energy & stamina

Better body composition (fat loss / muscle)

Stronger libido / sexual performance support

Better mood & stress resilience

Better focus / mental clarity

Better sleep & recovery

Healthy aging / longevity optimization

Section 4: Quick safety + readiness

1. Have you ever used testosterone therapy before?

Yes No

If yes:

Topical Injections Pellets Other

2. Do you want to preserve fertility in the next 12–18 months? (Important for TRT pathway decisions.)

Yes No Not sure

3. Any of the following? (check all that apply) This is not a medical intake; it’s a qualification layer.

Diagnosed sleep apnea (or heavy snoring)

History of blood clots

Prostate cancer history (self)

Significant urinary symptoms

Uncontrolled high blood pressure

None of the above

Screening Result (ADAM):

Results

If “Yes” to #1 or #7, or “Yes” to 3+ questions:

You screened positive for testosterone-related symptom patterns.

This does not diagnose low testosterone. The next step is a clinician review and lab confirmation when clinically appropriate.

If not:

You did not screen positive on ADAM today.

If symptoms persist, we can still evaluate other high-impact contributors (sleep, stress load, metabolic health, thyroid patterns, nutrient status, medications).

Ready for a real plan (not guesswork)?

Book your Men’s Hormone Optimization Consultation to review your screening and discuss the smartest next step.

You can keep guessing, or you can get a clinician-guided strategy backed by labs, analysis, and a clear implementation plan.

Screening → labs when appropriate → individualized plan → follow-through→ perform at your best.

Your information will be encrypted.