Wellness Firm - 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* This field is required.

Never

Mild

Moderate

Severe

6

MOOD CHANGES* This field is required.

Never

Mild

Moderate

Severe

7

DECREASED MENTAL ABILITY* This field is required.

Never

Mild

Moderate

Severe

8

EXCESSIVE SWEATING* This field is required.

Never

Mild

Moderate

Severe

9

HOT FLASHES / NIGHT SWEATS* This field is required.

Never

Mild

Moderate

Severe

10

WEIGHT GAIN* This field is required.

Never

Mild

Moderate

Severe

11

DECREASED SEX DRIVE* This field is required.

Never

Mild

Moderate

Severe

12

INABILITY TO MAINTAIN AN ERECTION* This field is required.

Never

Mild

Moderate

Severe

13

SLEEP PROBLEMS* This field is required.

Never

Mild

Moderate

Severe

14

DECREASED MUSCLE STRENGTH* This field is required.

Never

Mild

Moderate

Severe

15

COLD HANDS & FEET* This field is required.

Never

Mild

Moderate

Severe

16

HAIR LOSS* This field is required.

Never

Mild

Moderate

Severe

17

JOINT PAIN* This field is required.

Never

Mild

Moderate

Severe

18

ALL OVER HAIR LOSS & BREAKAGE* This field is required.

Never

Mild

Moderate

Severe

19

DRY, ITCHY SKIN* This field is required.

Never

Mild

Moderate

Severe

22

ADDITIONAL COMMENTS* This field is required.