1

 
1 Have we identified your name and address correctly?
  • A - Yes
  • B - No
A
2 Did you take a testosterone test?
  • A - Yes
  • B - No
Don't remember
3 Did you take this testosterone test due to what you felt was a lowered libido (sex drive)?
  • A - Yes
  • B - No
If so please proceed.
Yes (If I did take it)
4 Has your libido always been a low or historically low?
  • A - Yes
  • B - No
A
5 Or, have you recently notices a reduced libido?
  • A - Yes
  • B - No
B
6 Would you like to correct your libido?
  • A - Yes
  • B - No
If so please proceed.
A
7 Are you married?
  • A - Yes
  • B - No
A
8 How would you describe the quality of your marriage?
  • A - Very Good
  • B - Good
  • C - Bad
  • D - Very Bad
D
9 Has your marital status changed since you had your testosterone level checked? 
  • A - Yes
  • B - No
B
10 How many times have you been married?
  • Answer.
1
11 How many times has your husband been been married?
  • Answer.
1
12 How long have you been married to your present husband?
  • Answer in years.
21
13 How would your husband describe the quality of your marriage?
  • A - Very Good
  • B - Good
  • C - Bad
  • D - Very Bad
D
14 Have you had a full hysterectomy?
  • A - Yes
  • B - No
B
15 Have you had a partial hysterectomy?
  • A - Yes
  • B - No
B
16 Have you had any cervical abnormalities?
  • A - Yes
  • B - No
B
17 Have you been diagnosed with breast cancer?
  • A - Yes
  • B - No
B
18 Have you been diagnosed with any other reproductive abnormalities?
  • A - Yes
  • B - No
B
19 Have you ever been diagnosed with any cancers?
  • A - Yes
  • B - No
B
20 Are you presently under treatment for any mental or emotional disorders?
  • A - Yes
  • B - No
B
21 Have you ever undergone treatment for mental or emotional disorders?
  • A - Yes
  • B - No
B
22 Have you and your husband ever undergone marital counseling?
  • A - Yes
  • B - No
B
23 Have you or your husband ever undergone counseling from anyone in the psychiatric, psychological or mental health field?
  • A - Self Yes
  • B - Self No
  • C - Husband Yes
  • D - Husband No
BD
24 Do you feel like you suffer from depression?
  • A - Yes
  • B - No
A
25 Do you regularly feel tired or run down?
  • A - Yes
  • B - No
A
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