Condensed (Follow Up) BHRT Evaluation

CONFIDENTIAL FEMALE HORMONE EVALUATION
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Symptom Assessment

Using the following multiple choice questions below, please select all options that apply (when symptoms occur and/or the severity of symptom)
Hot Flashes*

Ocuring in the Morning (AM)Ocuring MiddayOcurring in the Evening (PM)Occuring ALL DAY
Intensity of each time of day (label each time of day as mild, moderate, or severe)*
Intensity of each time of day (label each time of day as mild, moderate, or severe)*
Intensity of each time of day (label each time of day as mild, moderate, or severe)*
Night Sweats*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Night Sweat Symptoms:
Vaginal Dryness*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Vaginal Dryness Symptoms:
Incontinence*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Incontinence Symptoms:
Bleeding Changes*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Bleeding Changes:
Fibrocystic Breasts*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Symptoms:
Weight Gain*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Weight Gain Symptoms:
Fluid Retention:*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Fluid Retention Symptoms:
Dry Skin / Hair:*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Dry Skin / Hair Symptoms:
Hair Loss:*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Hair Loss Symptoms:
Anxiety*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Anxiety Symptoms:
Depression*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Depression Symptoms:
Mood Swings*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Mood Swings:
Irritability*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Irritability Symptoms:
Headaches*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Headaches:
Breast Tenderness*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Breast Tenderness:
Cramps*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Cramps:
Difficulty Falling Asleep*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Difficulty in Falling Asleep:
Difficulty Staying Asleep*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Difficulty in Staying Asleep:
Fatigue*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Fatigue:
Loss of Memory*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Loss of Memory:
Foggy Thinking*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Foggy Thinking Symptoms:
Acne*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Acne Symptoms:
Arthritis*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Arthritis Symptoms:
Decreased Sex Drive*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Sex Drive:
Harder to Reach Climax*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Difficulty to Reach Climax:
Stress*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Stress:
Sugar Cravings*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Sugar Cravings:
Excess Facial/Body Hair*

AbsentMild SymptomsModerate SymptomsSevere Symptoms
Describe Facial and/or Body Hair:
Other Symptoms:
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Follow-Up / Progress CheckThis up to 30-minute consultation is designed to assess your progress, review any changes in symptoms, and adjust your treatment plan as needed. Using your latest medical history and lab results, I will ensure your therapy remains aligned with your health goals, optimizing your hormone balance, energy, and overall well-being.
$100.00

Total

$0.00

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CONFIDENTIAL FEMALE HORMONE EVALUATION

Symptom Assessment

Payment