Hormone replacement survey
Would you benefit from hormone replacement therapy? Let's check!
Name
First Name
Last Name
Email
example@example.com
Date
-
Month
-
Day
Year
Date
Are you biologically male (have male organs) or female (have female organs)?
Male
Female
Which of the following symptoms apply to you currently (in the last 2 weeks)? Please mark the appropriate box for each symptom. For symptoms that do not currently apply or no longer apply, mark “never”.
Rows
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Sever (4)
Hot Flashes
Sweating (night sweats or increased episodes of sweating)
Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)
Depressive mood (feeling down, sad, on the verge of tears, lack of drive)
Irritability (mood swings, feeling aggressive, angers easily)
Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)
Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)
Sexual problems (change in sexual desire, in sexual activity and/or organism and satisfaction)
Bladder problems (difficulty urinating, increasing need to urinate, incontinence)
Vaginal symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse)
Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)
Difficulties with memory
Problems with thinking, concentrating or reasoning
Difficulty learning new things
Trouble thinking of the right word to describe persons, places or things when speaking
Increase in frequency or intensity of headache or migraines
Hair loss, thinning or changing in texture of hair
Feel cold all the time or have cold hands or feet
Weight gain or difficulty losing weight despite diet and exercise
Dry or wrinkled skin
Calculation
Which of the following symptoms apply to you currently (in the last 2 weeks)? Please mark the appropriate box for each symptom. For symptoms that do not currently apply or no longer apply, mark “never”.
Rows
Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Sever (4)
Increased need for sleep or falls asleep easily after a meal
Sweating (night sweats or increased episodes of sweating)
Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)
Depressive mood (feeling down, sad, lack of drive)
Irritability (mood swings, feeling aggressive, angers easily)
Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)
Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)
Sexual problems (change in sexual desire or in sexual performance)
Bladder problems (difficulty urinating, increasing need to urinate)
Erectile changes (less strong erections, loss of morning erections)
Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)
Difficulties with memory
Problems with thinking, concentrating or reasoning
Difficulty learning new things
Trouble thinking of the right word to describe persons, places or things when speaking
Increase in frequency or intensity of headache or migraines
Rapid hair loss or thinning
Feel cold all the time or have cold hands or feet
Weight gain, increased bell fat, or difficulty losing weight despite diet and exercise
Infrequent or absent ejaculations
Calculation
Remember your score and press submit to see your results!
Submit
Should be Empty: