Questionnaire

Tell us a little bit about yourself and your goals - the information is reviewed by the provider and may be used to determine your eligibility for treatment.

Select Product(Required)

TRT

What are your main goals with TRT?(Required)

More Energy

Increased Libido

Muscle Mass & Strength

Better Mood

Cognitive Focus

Have You Ever Been Diagnosed with Low Testosterone?(Required)

Yes

Have You Previously Been on TRT?(Required)

Yes

Is maintaining fertility important to you?(Required)

Very important

Somewhat important

Not important

Symptoms(Required)

Low energy or fatigue

Decreased sex drive (libido)

Erectile dysfunction

Difficulty building or maintaining muscle mass

Mood swings, irritability, or anxiety

Difficulty concentrating or mental fog

Increased body fat or weight gain

Trouble sleeping or poor sleep quality

Others

What are your primary goals with medical weight loss?(Required)

Weight reduction

More energy or stamina

Appetite or craving control

Improved bloog sugar or metabolic health

Boosting self-confidence and body image

Other

Have you ever used a prescription weight loss medication before?(Required)

Yes

If yes, which type have you tried before?(Required)

GLP-1 medication such as semaglutide or tirzepatide

Phentermine

Other

Are you experiencing any of the following symptoms?(Required)

Low energy or fatigue

Shortness of breath with activity

Difficulty losing weight despite diet and exercise

Joint pain in knees, hips of back due to extra weight

Constant hunger or cravings

Low mood or self-esteem

Sleep problems

Other

What best describes the concern you are seeking help with?(Required)

Difficulty achieving an erection

Difficulty maintaining an erection

Erections are less firm than desired

Performance varies depending on the situation

Other

How long have you been experiencing this issue?(Required)

Less than 3 months

3 to 6 months

More than 6 months

Not sure

How often does this issue occur?(Required)

Occasionally

About half the time

Most of the time

Almost always

Have you used any treatment for erectile dysfunction before?(Required)

Yes

Which have you tried?(Required)

Sildenafil or tadalafil

Other prescription medication

Over the counter supplements

Which of the following symptoms are you experiencing?(Required)

Poor or inconsistent sleep

Low energy or fatigue

Slower recovery after exercise

Increased body fat

Decreased muscle tone

Muscle weakness

Low libido

Slowed metabolism

All of the above

What are your goals?(Required)

Improved sleep quality

Increased energy and recovery

Body composition or fat loss support

Muscle tone or strength support

Overall wellness or longevity support

Mental clarity and focus

Have you previously used any peptide or hormone-based therapy?(Required)

Yes

If yes, what have you used?(Required)

Peptide therapy

Testosterone or other hormone therapy

Other

How would you describe your current activity level?(Required)

Sedentary

Light activity

Regular exercise

Highly active

Which of the following symptoms are you experiencing?(Required)

Low energy or fatigue

Brain fog or trouble focusing

High stress or feeling burned out

Poor sleep quality

Slow recovery from physical or mental strain

General feeling of low wellness

All of the above

What are your goals?(Required)

Increase energy levels

Improve mental clarity or focus

Support recovery from stress or burnout

Enhance overall wellness or vitality

Support healthy aging or longevity

Improve motivation or productivity

Message to the provider(Required)

Name(Required)

First Last

Phone(Required)

Date of Birth(Required)

Month

Day

Year

Must be 23 above

Products

Contact

info@activ8-health.com

(602) 932-2888