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About
Services
Hormone Replacement Therapy
Wellness
Weddings
Blog
FAQ
Events
Book Now
Hormone Replacement Therapy
BioTE Health Assessment for Women
Female Symptom Questionnaire
Step
1
of
4
25%
Name
*
First
Last
Email Address:
*
Phone Number:
*
Today's Date:
MM slash DD slash YYYY
Date of Birth:
*
MM slash DD slash YYYY
Last Menstrual Period:
*
MM slash DD slash YYYY
Current Weight:
*
Birth Control Method:
*
Symptoms
Which of the following symptoms apply to you currently (in the last 2 weeks)? Please mark the appropriate box for each symptom. For symptoms that do not currently apply or no longer apply, mark "never".
Hot Flashes:
*
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Sweating
*
(night sweats or increased episodes of sweating):
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Sleep problems
*
(difficulty falling asleep, sleeping through the night or waking up too early):
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Depressive mood
*
(feeling down, sad, on the verge of tears, lack of drive):
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Irritability
*
(mood swings, feeling aggressive, angers easily):
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Anxiety
*
(inner restlessness, felling panicky, feeling nervous, inner tension):
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Physical exhaustion
*
(general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation):
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Sexual problems
*
(change in sexual desire, in sexual activity and/ or orgasm and satisfaction):
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Bladder problems
*
(difficulty in urinating, increased need to urinate, incontinence):
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Vaginal symptoms
*
(sensation of dryness or burning in vagina, difficulty with sexual intercourse):
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Joint and muscular symptoms
*
(joint paint or swelling, muscle weakness, poor recovery after exercise):
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Difficulties with memory:
*
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Problems with thinking, concentrating or reasoning:
*
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Difficulty learning new things:
*
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Trouble thinking of the right word to describe persons, places or things when speaking:
*
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Increase in frequency of intensity of headaches and migraines:
*
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Hair loss, thinning or change in texture of hair:
*
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Feel cold all the time or have cold hands or feet:
*
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Weight gain or difficulty losing weight despite diet and exercise:
*
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Dry or wrinkled skin:
*
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Hidden
Total Score:
