Are you age 35 or older?	Yes	No

Do you tire more easily?	Yes	No

Is it more difficult to get and stay in shape?	Yes	No

Is there less desire to be active and/or exercise and the time to recover is longer?	Yes	No

Have you lost some of the Zest for life -- the old attack the day attitude?	Yes	No

Are you eating the same or less and putting on weight?	Yes	No

Irritability -- are you sad and/or grumpy?	Yes	No

Have you lost some of your mental quickness and reaction time?	Yes	No

Do you have a decrease in libido (sex drive)?	Yes	No

Decrease in number of morning erections?	Yes	No

Are your erections less strong?	Yes	No

Are you falling asleep after dinner?	Yes	No

Has there been a deterioration in your work performance?	Yes	No

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