Female Hormone Therapy  Questionnaire
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Email *
By checking this box, I agree to use electronic records and signatures and I acknowledge that I have read the related consumer disclosure. (required)
Full Name *
Date *
Phone Number *
Physical Exhaustion (Fatigue, lack of energy, stamina, or motivation) *
Sleep Problems (Difficulty falling asleep or sleeping through the night) *
Irritability (Mood swings, feeling aggressive, angers easily) *
Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous) *
Decline in drive or interest (loss of "zest for life", feeling down or sad) *
Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise) *
Difficulties with memory (concentration, finding the right word, or retaining information) *
Vaginal dryness or difficulty with sexual intercourse *
Sexual Problems (change in desire, activity, orgasm and/or satisfaction) *
Sweating (night sweats or increased episodes of sweating *
Hot Flashes (burst that starts in chest and lasts for short duration) *
Hair loss, thinning or change in texture of hair *
Feeling cold all the time, having cold hands or feet *
Headaches or migraines (increase in frequency or intensity) *
Weight (difficulty losing weight despite diet/exercise) *
Bladder problems (difficulty in urinating, increased need to urinate, incontinence) *
Other symptoms or unique health circumstances to take Into consideration: *
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