Lotus Med Spa Symptom Checklist

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

3

Email* This field is required.

example@example.com

4

Gender* This field is required.Please select a gender to show symptoms

Male

Female

5

FATIGUE

Never

Mild

Moderate

Severe

6

MOOD CHANGES

Never

Mild

Moderate

Severe

7

DECREASED MENTAL ABILITY

Never

Mild

Moderate

Severe

8

EXCESSIVE SWEATING

Never

Mild

Moderate

Severe

9

HOT FLASHES / NIGHT SWEATS

Never

Mild

Moderate

Severe

10

WEIGHT GAIN

Never

Mild

Moderate

Severe

11

DECREASED SEX DRIVE

Never

Mild

Moderate

Severe

12

INABILITY TO MAINTAIN AN ERECTION

Never

Mild

Moderate

Severe

13

SLEEP PROBLEMS

Never

Mild

Moderate

Severe

14

DECREASED MUSCLE STRENGTH

Never

Mild

Moderate

Severe

15

COLD HANDS & FEET

Never

Mild

Moderate

Severe

16

HAIR LOSS

Never

Mild

Moderate

Severe

17

JOINT PAIN

Never

Mild

Moderate

Severe

18

ALL OVER HAIR LOSS & BREAKAGE

Never

Mild

Moderate

Severe

19

DRY, ITCHY SKIN

Never

Mild

Moderate

Severe

22

ADDITIONAL COMMENTS* This field is required.