BioTE & Hormone Checklist for Women
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient ID # (existing patients only)
Email (potential new patients only)
example@example.com
Phone Number (potential new patients only)
Please enter a valid phone number.
Format: (000) 000-0000.
Hormone related symptoms - please select symptoms based on how you are feeling currently. If you have 3 or more symptoms that are moderate to severe, you are likely a candidate for a hormone consultation and hormone therapy.
Rows
Never
Mild
Moderate
Severe
Depressive mood
Anxiety
Memory issues
Confusion or brain fog
Decreased libido or sex drive
Difficult to climax sexually
Sleep problems
Mood changes or irritability
Tension
Migraines or severe headaches
Bloating
Weight gain
Belly fat
Breast tenderness
Vaginal dryness
Hot flashes
Night sweats
Dry and wrinkled skin
Hair is falling out
Feeling cold all the time
Feeling hot all the time
Swelling all over body
Joint pain
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