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Ageless Aesthetics - Symptom Checklist
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9
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1
NAME
*
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First Name
Last Name
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2
EMAIL
*
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example@example.com
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3
GENDER
*
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Male
Female
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4
FATIGUE
*
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Never
Mild
Moderate
Severe
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5
MOOD CHANGES
*
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Never
Mild
Moderate
Severe
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6
DECREASED MENTAL ABILITY
*
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Never
Mild
Moderate
Severe
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7
EXCESSIVE SWEATING
*
This field is required.
Never
Mild
Moderate
Severe
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8
HOT FLASHES / NIGHT SWEATS
*
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Never
Mild
Moderate
Severe
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9
WEIGHT GAIN
*
This field is required.
Never
Mild
Moderate
Severe
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10
DECREASED SEX DRIVE
*
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Never
Mild
Moderate
Severe
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11
INABILITY TO MAINTAIN AN ERECTION
*
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Never
Mild
Moderate
Severe
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12
COLD HANDS & FEET
*
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Never
Mild
Moderate
Severe
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13
SLEEP PROBLEMS
*
This field is required.
Never
Mild
Moderate
Severe
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14
ALL OVER HAIR LOSS & BREAKAGE
*
This field is required.
Never
Mild
Moderate
Severe
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15
DECREASED MUSCLE STRENGTH
*
This field is required.
Never
Mild
Moderate
Severe
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16
DRY, ITCHY SKIN
*
This field is required.
Never
Mild
Moderate
Severe
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17
HAIR LOSS
*
This field is required.
Never
Mild
Moderate
Severe
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18
JOINT PAIN
*
This field is required.
Never
Mild
Moderate
Severe
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19
Male Family History
*
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Check All That Apply
Heart Disease
Diabetes
Osteoporosis
Alzheimer's Disease
Prostate Cancer
N/A
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20
Female Family History
*
This field is required.
Check All That Apply
Heart Disease
Diabetes
Osteoporosis
Alzheimer's Disease
Breast Cancer
N/A
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21
ADDITIONAL COMMENTS
*
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Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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22
Signature
*
This field is required.
There is a consultation fee collected at time of meeting. Please sign verifying that payment will be collected at meeting. $150 concierge fee per appointment
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23
Please verify that you are human
*
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HORMONE OPTIMIZATION Form
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