Firebird Vitality
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Assessment
Firebird Vitality Assessment
Name
(Required)
First
Last
Age Range
(Required)
18 – 25
25 – 35
35 – 45
45 – 55
55+
Phone
(Required)
Email
(Required)
ADAM Questionairre
1. Do you have a decrease in libido (sex drive)?
Yes
No
2. Do you have a lack of energy?
Yes
No
3. Do you have a decrease in strength and/or endurance?
Yes
No
4. Have you lost height?
Yes
No
5. Have you noticed a decreased "enjoyment of life"?
Yes
No
6. Are you sad and/or grumpy?
Yes
No
7. Are your erections less strong?
Yes
No
8. Have you noticed a recent deterioration in your ability to play sports?
Yes
No
9. Are you falling asleep after dinner?
Yes
No
10. Has there been a recent deterioration in your work performance?
Yes
No