Hormone Replacement Therapy

BioTE Health Assessment for Women

Female Symptom Questionnaire

"*" indicates required fields

Step 1 of 4

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Pregnant or Trying to become Pregnant*
Uterus present?*
Still having a menstrual cycle?*


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:*
(night sweats or increased episodes of sweating):
Sleep problems*
(difficulty falling asleep, sleeping through the night or waking up too early):
Depressive mood*
(feeling down, sad, on the verge of tears, lack of drive):
(mood swings, feeling aggressive, angers easily):