BioTE Health Assessment for Women

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)

Hormone Replacement Therapy