Health Assessment for WOMEN
please check 1 box
Email address *
Patient Name: *
Your answer
Patient Phone Number *
Your answer
Fatigue *
Mood Changes *
(irritability, anxiety/nervousness, depression)
Decreased Mental Ability *
(memory loss, confusion, loss of focus)
Hot Flashes / Night Sweats *
Weight Gain *
(bloating, excessive belly fat, inability to lose weight)
Decreased Sex Drive *
(vaginal dryness)
Sleep Problems *
(can't stay sleep, can't fall asleep)
Cold Hands & Feet / Always Cold *
Hair Loss / Breakage *
Dry Wrinkled Skin *
Family History (check all that apply) *
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