Female Hormone Health Assessment
Administered by Dr. Joseph Bandeira of Premier Medical Concierge located at 9655 Tamiami Trail N., Suite 202, Naples, FL 34108. Phone: 239-631-6780.
Your Name:
*
First Name
Last Name
Best Email:
*
example@example.com
Best Phone Number:
*
Please enter a valid phone number.
Today's Date:
*
-
Month
-
Day
Year
Date
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Next
YOUR SYMPTOMS
For each symptom listed below, please choose the appropriate response based on the severity you may be experiencing. (All answers will be kept confidential.)
Physical Fatigue (lack of energy, stamina, or motivation)
*
NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Sleep Problems (difficulty falling asleep or sleeping through the night)
*
NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Irritability (mood swings, feeling aggressive, easily angered)
*
NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Anxiety (feeling overwhelmed, panicky or nervous)
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NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Decline in Drive or Interest (loss of "zest for life," feeling down or sad)
*
NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Joint and Muscular Symptoms (poor recovery after workout, inability to add muscle, joint pain, muscle weakness)
*
NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Difficulties with Memory (concentration, finding the right word, or retaining information)
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NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Vaginal Dryness (difficulty with sexual intercourse)
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NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Sexual Problems (change in desire, activity, orgasm and/or satisfaction)
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NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Sweating (night sweats or increased episodes of sweating)
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NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Hot Flashes (burst that starts in chest and lasts for short duration)
*
NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Hair Loss (thinning or change in texture of hair)
*
NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Cold Sensations (feeling cold all the time, cold hands or feet)
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NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Headaches or Migraines (increase in frequency or intensity)
*
NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Difficulties with Weight (difficulty losing weight despite diet and exercise)
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NONE
MILD
MODERATE
SEVERE
VERY SEVERE
Bladder Problems (difficulty urinating or increased need to urinate)
*
NONE
MILD
MODERATE
SEVERE
VERY SEVERE
LAST QUESTION! Are there any other symptoms or unique health circumstances to consider? If so, please briefly describe them here:
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