Full Name
Email
*
Phone
*
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Do you experience the following symptoms?
Hot Flashes or episodes of sweating
Internet Search
Social Media
Referral
Other
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How severe are your symptoms?
None
Mild
Moderate
Severe
Extremely Severe
Do you have joint or muscular discomfort? (pain in joints)
None
Mild
Moderate
Severe
Extremely Severe
Do you have cold hands and feet?
None
Mild
Moderate
Severe
Extremely Severe
Do You have daily bowl movements?
Yes
No
Do you have gas, bloating, or pain after eating?
Yes
No
How severe are your symptoms of heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness of chest.
None
Mild
Moderate
Severe
Extremely Severe
How would you rate your symptoms of Irritability (feeling nervous, inner tension, feeling aggressive).)
None
Mild
Moderate
Severe
Extremely Severe
How would you rate your feelings of anxiety (inner restlessness, feeling panicky).
None
Mild
Moderate
Severe
Extremely Severe
How often to you experience sleep problems (difficulty falling asleep, difficulty sleeping through the night, waking up early).
None
Mild
Moderate
Severe
Extremely Severe
How severe are your symptoms of depressive mood (feeling down, sad, on verge of tears, lack of drive, mood swings).
None
Mild
Moderate
Severe
Extremely Severe
How would you rate your symptoms of dryness of vagina (sensation of dryness or burning in vagina, difficulty with sexual intercourse).
None
Mild
Moderate
Severe
Extremely Severe
Please select your weekly activity level based on activity that accelerates your heart rate and breathing.
None
1 time weekly
2-3 times weekly
4-5 times weekly
6-7 times weekly
Have you had any previous hormone therapy?
Yes
No
