Hormonal Health Survey


Contact Information

Name:
Age:
Gender:
Email:

Symptoms

I have gained weight or noticed my clothes are fitting tighter and tighter.
None Mild Moderate Severe
I'm feeling slower and more sluggish and have less energy.
None Mild Moderate Severe
I'm experiencing increased anxiety and can become irritated more easily.
None Mild Moderate Severe
I find that I am less and less interested in sexual intimacy or have pain on intercourse.
None Mild Moderate Severe
I feel my zest and excitement for life is fading.
None Mild Moderate Severe
I often feel moody or depressed.
None Mild Moderate Severe
My skin is looking thinner or blemished or wrinkled or sagging.
None Mild Moderate Severe
I have difficulty remembering names or places or simple things, like where I put something.
None Mild Moderate Severe
It is harder for me to concentrate or hear or see clearly at times.
None Mild Moderate Severe
I experience "hot flashes" during the day or sometimes wake from sleep sweating and hot.
None Mild Moderate Severe

Scientific Studies

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Printable Patient Forms

Complete the Health History and/or Request for Compounded Prescription forms by clicking the link below.

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Links of Interest

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