Biote Female Health Assessment, History & Symptoms
For CDSS Round 1
Patient Information
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Today's Date
*
-
Month
-
Day
Year
Date
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Weight (in pounds)
*
Height
*
Health Assessment
Please mark the appropriate box for each symptom you may be experiencing.
Symptoms
Rows
None
Mild
Moderate
Severe
Very Severe
Physical Exhaustion (fatigue, lack of energy, stamina or motivation)
Sleep Problems (difficulty falling asleep or sleeping through the night)
Irritability (mood swings, feeling aggressive, angers easily)
Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous)
Decline in drive or interest (loss of "zest for life," feeling down or sad)
Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise)
Difficulties with memory (concentration, finding the right word, or retaining information)
Vaginal dryness or difficulty with sexual intercourse
Sexual Problems (change in desire, activity, orgasm, and/or satisfaction)
Sweating (night sweats or increased episodes of sweating)
Hot Flashes (burst that starts in chest and last for short duration)
Hair loss, thinning or change in texture of hair
Feeling cold all the time, having cold hands or feet
Headaches or migraines (increase in frequency or intensity)
Weight (difficulty losing weight despite diet/exercise)
Bladder problems (difficulty in urinating, increased need to urinate, incontinence)
Other symptoms or unique health circumstances to take into consideration:
Patient Questions
Are you currently pregnant or trying to conceive?
Yes
No
Have you had a recent mammogram (within the last 12 months)?
Yes
No
Have you had a hysterectomy?
Yes
No
If yes to hysterectomy, type of hysterectomy:
Complete (uterus and ovaries removed)
Partial (uterus only removed)
Have you had a menstrual cycle (within the last 12 months)?
Yes
No
Have you had an ablation?
Yes
No
Are you on birth control?
Yes
No
If yes to birth control, Name of birth control:
Are you currently utilizing BHRT or HRT?
Yes
No
If yest to BHRT or HRT, select type of hormones:
Testosterone
Progesterone
Estrogen
Thyroid
List name and dose of hormone(s):
Rows
Yes
No
Are you currently on statins?
Are you a smoker?
Are you currently on oral nitrates?
Back
Next
Medical History
Select ALL that Apply
Cardiovascular Conditions:
Heart Attack or Stroke (within last 6 months)
Tachycardia
DVT or Blood Clot (within last 6 months)
Hypertension
Hyperlipidemia
Obstructive Sleep Apnea
Atrial Fibrillation
Gynecological Conditions:
Pre-Menstrual Syndrome
Endometriosis or History of Endometriosis
Fibrocystic Breast Disease
Fibroids or History of Fibroids
Polyps or History of Endometrial Polyps
Cancer:
Breast Cancer or History of Breast Cancer
Endometrial Cancer
Cervical Cancer
Ovarian Cancer
Thyroid Cancer or History of Thyroid Cancer
Except for Basal Cell Carcicoma, Any Other Cancers?
Other
Neurological Conditions:
Epilepsy or Seizure Disorder
Depression/Anxiety
Psychiatric Conditions
Migraine with Aura
Meningioma
Endocrine and Metabolic:
PCOS
Diabetes Type 2 or Insulin Resistance
Hyperthyroid
Hypothyroid
Multiple Endocrine Neoplasia Type-2
Autoimmune Conditions:
Diabetes Type 1
Hashimoto's Thyroiditis
Graves' Disease
Rheumatoid Arthritis
Multiple Sclerosis
Systemic Lupus (Erythematosus)
Psoriasis
IBS (Irritable Bowel Syndrome)
Crohn's Disease
Ulcerative Colitis
Organ Specific Conditions:
Liver Disease or History of Liver Disease
Kidney Disease or History of Kidney Disease
LAM (Lymphangioleiomyomatosis)
Osteoporosis or Osteopenia
HIV
Hepatitis
Hemochromatosis
Pancreatitis or History of Pancreatitis
History of Gall Bladder Disease
Polycythemia Vera (PV)
Back
Next
Symptoms and Concerns
Select ALL that Apply
Hot Flashes
Night Sweats
Vaginal Dryness
Decreased Interest in Sex
Inability To or Delayed Orgasm
Painful Intercourse
Urinary Incontinence
Frequent Urinary Tract Infection
Breast Tenderness
Weight Gain
Hair Loss
Hair Thinning
Thinning Eyebrows
Cold Hands or Feet
Brittle Nails
Dry or Flaking Skin
Lack of Energy (Fatigue)
Decreased Muscle Mass
Acne
Facial Hair
Dry Eyes
Joint Pain
Difficulty Sleeping
Mind Racing at Bedtime
Eating When Stressed
Submit
Should be Empty: