BHRT Symptom Survey

Hormone Health Survey

The hormone system is one of the important regulatory systems in your body. They act as messengers, designed to interact with specific target cells and organs and provoke a change or result. As we age, hormone production changes, and hormonal imbalance can occur as a result. Unbalanced hormones can have a variety of side effects and symptoms.

Many of the symptoms screened in this form could be the result of other conditions. However, when several of them are present, the liklihood that they are caused by hormone imbalance is high and warrants further investigation.

After completing this form, the next step will be to complete lab work to objectively discern where your levels are. You will receive a lab request to your email address upon submission of this form.
Amount of Energy *

(Less is Worse, more is Better)
Amount of Energy total*

Sleep Quality *

(Less is Worse, more is Better)
sleep quality total*

Mood Quality (depression, stress, anxiety vs. a good mood) *

(Less is Worse, more is Better)
mood quality total*

Pain *

(Less is Better, more is Worse)
Pain total*

Name*

First NameMiddle NameLast Name
DOB*

MonthDayYear
Date
Email (For sending you confirmation of submission. We will always keep your information private.)*
example@example.com
Phone Number (For following up with you about bio-identical hormone therapy. We will always keep your information private.)*
Please enter a valid phone number.
Birth Sex*

MaleFemale
Date*

MonthDayYear
Date
Awesome!

Just 12 more questions to screen you for symptoms of hormone imbalance.
Awesome!

Just 15 more questions to screen you for symptoms of hormone imbalance.

Do you need a hormone assessment lab request?*

YesNo
Lab order name
Lab order DOB
Lab order Date
Should be Empty: