Hormone Enhancement Self-Test/Questionnaire

If you feel you are a candidate for Human Growth Hormone Enhancement Therapy, we have a self-test for you to complete. Please feel free to complete the form and send Dr. Sutanto the results. We know that we can help you get back on track. It will be in two sections so complete both.

If the answer is yes, add or subtract the number of points.

Today, as compared to 10 years ago:

1. Do you often feel tired? +1

2. Do you feel happy most of the time? -2

3. Do you often go through mood swings? +2

4. Do you anger easily? +2

5. Are you depressed often? +1

6. Do you often feel anxious or stressed? +1

7. Do you feel you work too hard? +2

8. Do you look forward to retirement (not to pursue an activity but to do less? +2

9. Do you keep in touch with friends? -1

10. Do you maintain an interest in sex? -1

11. Is your sex life declining? +2

12. Do you have trouble falling or staying asleep? +2

13. Do you feel well rested after sleep? -1

14. Do you find yourself forgetting things? +2

15. Do you find it harder to think clearly? +2

16. Do you use memory aids (lists)? +2

17. Do you have problems concentrating? +2

18. Are you in poor physical shape? +2

19. Are you more than 20% above your ideal weight? +2

20. Is it very difficult for you to lose weight? +1 21. Have you developed a "spare tire" or "love handles"? +1

22. Does your musculature look youthful? -2

23. Do you feel your overall health is good?-2

24. Do you often get colds or feel sick? +2

(next page)

Hormone Therapy