ADAM Questionnaire – CY Men’s Health Clinic

CY Men’s Health Clinic — ADAM Questionnaire

Androgen Deficiency in the Aging Male screening questionnaire for symptoms compatible with testosterone deficiency. This tool is for symptom screening and does not diagnose low testosterone without clinical evaluation and appropriate laboratory confirmation.

1. Patient Information

Patient Name

Date of Birth

Age

Date

Phone

Preferred Language

Reason for Questionnaire

2. ADAM Questionnaire

Important: A positive ADAM screen suggests symptoms compatible with androgen deficiency, but it does not confirm hypogonadism. Diagnosis requires clinician review and testosterone testing.

Please answer Yes or No for each question based on your recent symptoms.

3. Result Summary

Click “Calculate Result” or “Generate Note” to calculate ADAM result.

Yes Answers / 10

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ADAM Screen Result

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Key Criteria

4. Clinical Context / Lab Documentation

These fields help connect the screening questionnaire to a safe TRT evaluation.

Total Testosterone #1

Date / Time #1

Total Testosterone #2

Date / Time #2

Prior Low Testosterone Diagnosis?

Currently on TRT?

Candidate Status

Additional Clinical Notes

5. Patient Handwritten Signature

Patient may sign below using mouse, finger, or stylus.

Patient Signature Name Printed

Signature Date

Signature Captured?

Sign inside the box above.

6. Generated Chart Note

Use this as a draft. Review clinically before saving in the EHR.