Female Hormone Health Assessment
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Email address *
First and Last Name *
Your answer
Today's Date *
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Date of Birth *
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For each symptom on the left select the severity on the right
never
mild
moderate
severe
Depressed mood
Fatigue
Memory Loss
Mental Confusion
Decreased sex drive/libido
Sleep problems
Mood changes/Irritability
Tension
Migraine/severe headaches
Difficult to climax sexually
Bloating
Weight Gain
Breast tenderness
Vaginal Dryness
Hot flashes
Night Sweats
Dry and wrinkled skin
Hair is falling out
Cold all the time
Swelling all over the body
Joint pain
Family History
No
Yes
Heart Disease
Diabetes
Osteoporosis
Alzheimer's Disease
Breast Cancer
A copy of your responses will be emailed to the address you provided.
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